Spring Green Animal Hospital

506 Rainbow Road
Spring Green, WI 53588

(608)588-3535

www.sgah.info

Canine Wellness Check In Form

Thank you for scheduling a Wellness Exam Visit with your pet! We look forward to your visit! 

Please fill out the form below to help us best serve you and your pet during their visit.

Thank you for your time!

Canine Wellness Check In Form

Email (This should be the main email you would like us to use for your account) (required)

Dog's Name (required)

Owner's Name (That account is under in our system) (required)

Who will be bringing your dog to their appointment?

What is the best contact number for that person during the appointment time?

Current Mailing Address
Street Address
City
,
State / Province
Zip / Postal Code
Main Contact Phone Number
Phone TypePhone Number
Is this a cell phone that can accept text message reminders from us?

Yes
No


Has your dog shown any of the following signs or symptoms? If no, leave blank. If yes, please explain.
Coughing, gagging, or wheezing?

Vomiting, Diarrhea or Scooting on rear end?

Red gums, offensive breath, excessive drooling, or sensitivity while chewing?

Lameness or difficulty when getting up?

Lethargy, listlessness or anxiety (hiding or uncontrollable shaking)?

Unusual body odors, itching, scratching, poor hair coat, hair loss, skin problems or ear odor/head shaking?

Lumps or bumps?

Has your dog shown a significant change in any of the following? If no, leave blank. If yes, please explain.
Change in appetite or increase in drinking?

Weight gain or loss?

Change in behavior, training or behavioral issues?

Difficulty in Hearing or with Vision?

ENVIRONMENTAL EXPOSURES AND TESTING
Is your dog primarily:

Indoor Dog
Outdoor Dog
50/50


Tick Exposure Level:

High
Moderate
Very Low


Mosquito Exposure Level:

High
Moderate
Very Low


We recommend YEARLY testing for the following diseases:
- Heartworm Disease: Contracted by a single mosquito bite, fatal in not detected, symptoms take 1-2 years to develop
- Lyme Disease: Contracted by a Deer Tick bite. Most common infectious disease we see in dogs! Most cases can be treated with antibiotics, rarely it can lead to severe and fatal complications
- Anaplasma: Similar in many ways to Lyme Disease, except symptoms can be very vague, chronic, or recurrent
Routine Screening Tests: I would like:

Heartworm /Lyme/ Anaplasma test
Heartworm Only test
I decline screening at this time
I am unsure and would like to discuss further


PREVENTATIVE PRODUCTS- Would you like us to dispense any of the following today?
Flea / Tick Prevention:

Seresto - 8 month collar
Frontline Gold - Monthly liquid spot-on
Nexgard / Credelio - Monthly Oral
I am unsure and would like to discuss


Heartworm / Intestinal Parasite Prevention

Seasons worth - Monthly Chewable
12 month supply - Monthly Chew
Seasons worth of Revolution (for small dogs without tick concerns) - monthly topical
Other (make a note in other box below)


Other
Would you like your dog's nails trimmed today? (There is a fee for this)

Yes
No


Do you have any other questions or comments about your dog today?

Senior Screening / Preventative Wellness Bloodwork Screening
When your pet is in for it's Annual Wellness Exam
We also offer the opportunity to have us perform some basic lab screening tests at a significant discount to ensure that your pets organs and metabolic functions are all working well. These tests are even more important if your pet is:
- Over 7 years old
- Will need general anesthesia for a surgical or dental procedure in the coming months
- Has any chronic medical conditions
- Receives regular medications for a chronic problem
Are you interested in Preventative Wellness Screening for your dog today?

Yes
No
I am unsure and would like to discuss further



Verify the reCAPTCHA: