Hurst Animal Clinic
640 Bedford-Euless Rd.
Hurst, TX 76053
817-282-1463
Your pet is here today for their annual physical and scheduled vaccinations. In order to provide
the best possible care, we would ask that you take a few minutes to answer the following
questions.
Today’s Date_________________________Email_________________________________________________
Your Name________________________________________________________________________________
Pet’s Name________________________________________________________________________________
Address___________________________________________________________________________________
City______________________________________________Zip Code_________________________________
Home Phone_________________________________Work Phone____________________________________
Cell Phone___________________________________Other_________________________________________
Is your pet:
□Exclusively Indoor (more inside than outside)
□Exclusively Outdoor (more outside than inside)
□Indoor/Outdoor (inside and outside equally)
Have you noticed any of the following?
Vomiting
Diarrhea
Coughing or sneezing
Getting tired
Wheezing
Difficulty getting up or around
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YES
NO
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Increase in water consumption
Change in urination habits
Itchy skin/licking self
Hair loss
Fleas or ticks
Changes in vision or hearing
Changes in appetite
Bad breath
New lumps
Are you interested in
microchipping your pet?
Are you interested in age
specific annual preventative
blood work?
YES
NO
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□Please discuss with me
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□Please discuss with me
While a comprehensive annual exam can tell us a lot about a pet, many diseases can be subtle
and slowly progressing. Just as it does with people, annual blood work allows us to identify
and address these conditions much sooner, before the pet shows serious signs of illness. Unless
the pet’s exam shows something else is needed, current cost is:
 $56 for animals ages 0-7
 $103.75-$135 for ages 8 and older, depending on what we are screening for
Please specify any other concerns you may have about your pet that you would like to discuss
with the doctor.
Signature______________________________________________________________Date_____________