Name: Lake Country Veterinary Care
Address: 2527 Cherry Valley Turnpike, Marcellus, NY, 13108, United States
Telephone: 315-673-4858
Price range: $

Please fill out this form to the best of your ability prior to your appointment. If you have any questions or concerns prior to your appointment please contact our office at 315-673-4858 or via email at [email protected]. We are looking forward to your visit!

Name *

First

Last

Pet Name *

At this time Lake Country is operating curbside. As a result, we will have you wait outside in your vehicle while your patient is taken inside the building for examination. Depending on the weather, the doctor will either come outside to discuss his/her findings or they will call you from inside the building to discuss. Please provide the number you wish us to use on the day of your appointment.

Phone *

Is this your pet's first visit with us? *

Yes
No

* If this will be your pet's first visit please make sure that any and all previous medical records are sent prior to your scheduled appointment *

What wellness/preventative care services are you interested in today? *

If 'Other', please specify: *

Has your pet ever had an adverse reaction to drugs, supplements, or vaccines? *

Yes
No

If your pet has adverse reactions to vaccinations, have you already given an antihistamine before today's appointment? *

Yes
No
Other

If 'Other', please specify: *

Is your pet currently receiving any parasite preventatives (i.e. heartworm, flea/tick)? * *

Yes
No

What heartworm and/or flea and tick prevention is your pet on? *

If 'Other', please specify: *

Will you need a refill of preventatives for your pet? *

Yes
No

If yes, what preventatives will you need a refill of? *

If 'Other', please specify: *

What do you feed your pet and how much? *

Does your pet have any chronic or recurring problems, injuries or illnesses? *

Yes
No

If yes, what is your pet's chronic or recurring condition *

Is your pet currently on any prescription medications or supplements? *

Yes
No

If yes, what medications or supplements does your pet receive? How much do you give and how often are they given?

Environmental / Lifestyle

Does your pet...

Medical Concerns

Do you have any concerns that you would like to address with the doctor? *

If 'Other', please specify: *

Signature *

Today's Date *

Annual Wellness Exam