Potomac Animal Wellness Services
4618 Indian Head Hwy
Indian Head, MD 20640
Phone: (301) 743-5411 Fax: (301) 753-5161
www.mdPAWSvet.com
Patient Drop Off History Form
Today’s Date ______________
Your name ____________________________ Your Pet’s Name _______________________________
We will need to be able to contact you or someone with permission to make medical and financial
decisions. Who will we be speaking with? ___________________________
1st choice phone number ______________________
2nd choice phone number ______________________
Reason for visit: ___________________________________________________________________
Vaccines: Check all that you would like doneDog- _____ Rabies*
Cat- _____ Rabies*
_____ DHPP*
_____ FVRCP*
_____ Bordetella*
_____ Feline Leukemia
_____ Lyme
_____ Leptospirosis
*required for grooming/boarding
_____ Influenza
Testing: _____ Fecal
_____ Heartworm/Lyme/Ehrlichia/Anaplasma test (dogs only)
_____ Feline Leukemia/FIV/Feline Heartworm (cats only)
Other bloodwork: _________________________________________________________________
Other services: Are there any other services that you would like done while your pet is here today?
_____ Anal gland expression
_____ Nail trim
_____ Bath
_____ Soft Paws Application
_____ Microchip
What diet is your pet eating? _______________________________________________________
When did your pet last eat? ________________
Has your pet ever had an adverse reaction to any medications? __________
If yes, please describe ________________________________________________________
Has your pet ever had an adverse reaction to any vaccines or any procedure? ___________
If yes, please describe ________________________________________________________
What heartworm preventative is your pet on? ____________________________________
What flea/tick preventative is your pet on? _______________________________________
Do you need a refill on any of your preventative medications? _______________________
Please list any medications that your pet is taking:
Medication
Dosage/Frequency
When last dose was given
Have you noticed any changes or do you have any concerns about any of the following in your pet?
_____ Eating more/less
_____ Drinking more/ less
_____ Bad Breath
_____ Weight gain
_____ Weight loss
_____ Urinating more/ less
_____ Vomiting
_____ Diarrhea
_____Itching/Scratching
_____ Difficulty rising
_____ Scooting rear
_____ Shaking head
_____ Masses
_____ Hair loss
_____ Limping
_____ Other ______________________________
Please describe what you have been seeing- include how long you have noticed the concern and how it
has progressed over time. How frequently is it happening?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Is this the first time you’ve noticed this issue? _____________________________________________
___________________________________________________________________________________
Have you tried any treatment? Did it help? ________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________