Name *

First

Last

Telephone number to reach you during your dog’s visit *

Email *

Dog's Name *

Which vaccinations, would you like us to administer today?

Rabies
Distemper-Parvo
Bordetella
I would like to speak to a veterinary team professional about my dog’s vaccines at the time of my appointment.

An important part of when your dog visits CountryVets for vaccinations is a wellness examination. Before administering any vaccines the veterinarian will examine your dog to look for any issues, and address any changes that you have noticed since your dog’s last examination.

Please list any concerns you have noticed since your dog’s previous wellness examination along with any previously existing conditions/diseases

What medications is your dog currently receiving?

What diet is your dog currently eating?

Does your dog live mostly: *

Indoors
Outdoors
Both

Is your dog currently receiving flea/tick preventative?

Yes
No

If yes, what is the product's name?

Is your dog currently on heartworm prevention?

Yes
No

Heartworm disease is a potentially fatal disease that is transmitted by mosquitoes. We recommend using a preventive called Proheart which is a long lasting heartworm injection. Monthly oral preventatives are available as well. We require a negative yearly heartworm test prior to purchase or administration of heartworm preventatives.

If yes, what is the product's name?

Would you like a heartworm test performed today?

Yes
No

Dog Wellness Appointment Form