Annual Exam Form

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Name *

First

Last

Phone *

Email *

Pet's Name *

Who should we contact to make medical decisions today? *

Owner (Named Above)
Someone Else (Named Below)

Name *

First

Last

Phone *

Email *

Reason for visit: (check all that apply)

Annual Physical
Heartworm/Tick test (dogs)
Deworming treatment
Annual physical - unsure of other services that are due. Would like to discuss with veterinarian.

Does your pet enjoy visiting the veterinary clinic?

Dog vaccines

Distemper, Parvo combination
Leptospirosis
Rabies
Lyme
Bordetella
Canine Influenza
Unsure, would like to discuss recommendations with veterinarian

Feline Vaccines

Feline upper respiratory/Distemper
Rabies
Feline Leukemia (FeLV)
Unsure, would like to discuss recommendations with veterinarian

Other procedures: (All procedures at additional cost)

Anal glands
Nail trim
Ear cleaning

Have you noticed any issues/problems with your pet? Are there any concerns for the following: (check all that apply)

Increase in appetite
Decrease in drinking
Itching/Scratching
Vomiting
Excessive Sleeping
Skin Masses (explain below)
Other (explain below)
Decrease in appetite
Weight Loss
Shaking Head
Diarrhea
Scooting
Car Sickness
Increase in drinking
Weight Gain
Bad Breath
Urination Issues
Difficulty Rising
Behavioral Problem

If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing? *

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure? *

What brand and type of food do you feed your pet?

How much do you feed? *

Free fed (food is offered always/whenever hungry)
Measured amount (specify how much and how often below)

If measured amount? *

First

Last

with the Many

Do you have insurance for your pet? *

Do you give your pet heartworm or flea/tick preventative? *

Do you wish to take home flea/tick/heartworm prevention today? *

Yes
No
Unsure, speak with a veterinarian about recommendations for my pet

What percentage of time does your pet spend outside?

Have you seen any fleas or ticks on your pet? *

Do you have other pets? *

Does your pet come into contact with other dogs? Please check all that apply *

None
Boarding
Grooming
Dog Parks
Other

Is your pet on any medications? *

Was your pet last seen by a veterinarian at Calhan Veterinary Clinic? *

Once your pet’s exam is completed, we will review the exam findings and recommendations. I understand that financial responsibilities for services rendered are due at the time of discharge. *

I have read and understand

Many of our patients love peanut butter as a snack while visiting our office, but if you or your pet have an allergy to peanut butter, please let us know. Can your pet have peanut butter? *

Yes
No
I have read and understand.

Social Media/Photo Permission: Do we have your permission to post photos of your pet online? *

I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above-mentioned pet. *

I agree
I disagree

Signature *

First

Last

Date *

Ready for a visit?

We proudly serve the pets of Calhan, Peyton, Falcon, Simla, Ramah, Elbert, and surrounding areas. We look forward to seeing you and your pet. Request an appointment for your pet by clicking the button below!

Call to schedule

Location

13425 N Calhan Hwy,
Calhan, CO 80808

Working Hours

Mon – Fri: 8:00am – 5:00pm

Sat & Sun: Closed

Contact Info

(719) 347-2702

questions@calhanvet.com

After hours services may be available pending staffing. Please call (719) 347-2702 for availability.