Deworming
Questionnaire Form

Save time during your appointment. Complete your deworming questionnaire form online from any device at any time before your visit.

Please fill out this form as completely and accurately as possible so we can get to know you and your pets before your visit.

Name *

First

Last

Email *

What is the best phone number for us to reach you? *

Pet's Name

Pet's Age

Pet's Gender:

Has your pet been seen by a vet within the last year?

Are you aware of any health problems?

In the last 4 weeks- did you notice weight loss/ vomiting/ diarrhea/ change in energy and/or appetite?

When did you last treat for internal (worms) and/or external parasites (fleas, ticks, mites)

Does your pet hunt/ eat rodents?

Are you aware of your pet having had fleas in the past year?

Have you observed any parasites on your pet, or its housemate's skin, fur, feces, vomit or about the anus or resting places?

With regards to Heartworm, has your pet been outside of BC? - to Heartworm endemic areas? If so, where?

What is your pets current weight? ________ kg (If you’re unable to weigh at home, you are welcome to use our scale)

Signature

Clear Signature

I, the owner, agree to withhold administering the dewormer medication for 24 hrs. pending Dr review and can be reached at phone number above.

Date

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