Canine Risk Assessment Form

Please answer the following questions to help us determine an appropriate vaccination protocol and parasite control for your dog.

Pet's name:(Required)

Owner's name:(Required)

Email(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone:(Required)

Home Phone:

How would you like us to send you reminders?

Postcard

Both

Do you take your dog hunting?(Required)

Do you take your dog hiking?(Required)

Do you take your dog swimming?(Required)

Do you have any standing bodies of water on your property (i.e. ponds) to which your dog has access?(Required)

Does your dog go to the kennel or to the groomer's frequently?(Required)

If 'yes', how frequently?

Do you have any wildlife coming into areas where your dog spends their time?(Required)

Do you take your dog to dog shows?(Required)

Does your dog go outside on a lead to urinate/defecate and then spend majority of their time outside?(Required)

Do you have any questions or concerns about a particular vaccination for your dog?(Required)

If 'yes', which ones?

Is your dog on heartworm preventative year round?(Required)

Is your dog on flea/tick preventative year round?(Required)

What food is your dog currently eating?(Required)

Is your dog on any medications and/or supplements?(Required)

Yes

If yes, please list (medication and dosing)

Do you have any concerns regarding your dog that you'd like to discuss today?

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Comments

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