CHECK IN ADDITIONAL INFORMATION

CHECK IN ADDITIONAL INFORMATION

(Please complete every question)

Animal Name______________________________ Owner Name______________________________ EMERGENCY CONTACT #_____________________

1. Are you the owner of this animal? YES NO

2. Does your pet live in the house with you? YES NO

3. Does your pet go outside? YES NO

4. Has your pet ever bitten or been aggressive to you, family members, or friends? YES NO

5. How long have you owned your pet? ____________ Date of Birth, if known _______________

6. Has your pet ever had surgery? YES NO Was there any reaction to anesthesia or other problems? YES NO

7. Is your pet healthy? YES NO Any vomiting or diarrhea? YES NO History of seizures, heart, liver, or kidney problems? YES NO Abnormal Runny nose or eye discharge? YES NO

8. Has your female pet ever had puppies or kittens? YES NO

9. Is your pet on any medication? YES NO Flea prevention? YES NO _________________________________ Heartworm prevention? YES NO ____________________________

10. Has your pet been dipped for fleas in the last 7 days? YES NO

11. Is there anything else about your pet's medical history or behavior we should know? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

1910 N. CHURCH ST. SUITE E GREENSBORO, NC 27405 336.333.5336 FAX:336.333.5166

Photo Release Form

I grant to Piedmont Communities Spay/Neuter & Wellness Clinic, its

representatives and employees the right to take photographs of me and/or my pet(s), and to copyright, use and publish the same in print and/or electronically.

I agree that Piedmont Communities Spay/Neuter & Wellness Clinic may use

such photographs of me and/or my pet(s) with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content.

The above may take photos of me and/or my pet(s)

The above may NOT take photos of me and/or my pet(s)

Signature: __________________________________________________________ Printed Name: ______________________________________________________ Address: ___________________________________________________________ City:_________________________________ State:________ Zip:_____________ Date:______________________________________________________________

1910-E N Church St Greensboro, NC 27405 336.333.5336 FAX:336.333.5166

Difference in Heartworm Prevention

Sentinel Spectrum

Heartgard Plus

Interceptor Plus

Heartworms Roundworms Hookworms Whipworms Tapeworms

Fleas Oral Monthly

Heartworms Roundworms Hookworms Guarantee for Whipworms

Oral Monthly

Heartworms Roundworms Hookworms Whipworms Tapeworms

Oral Monthly

Effitix

Difference in Flea/Tick Prevention

Frontline Gold

Nexgard

Credelio

Kills Adult Fleas Kills Ticks Kills Flea Eggs/Larvae Repels Fleas, Ticks, and

Mosquitos Topical

Monthly

Kills Adult Fleas Kills Adult Ticks Kills Flea Eggs/Larvae

Topical Monthly

Kills Adult Fleas Kills Adult Ticks

Oral Monthly

Kills Adult Fleas Kills Adult Ticks

Oral Monthly

HEARTWORM DISEASE:

THE SILENT KILLER

What are heartworms? Heartworms are a kind of roundworms that live in the heart and lungs of dogs, and other mammals. Heartworm infection is spread from one animal to another through mosquito bites. ALL dogs that live in warmer, southern climates like North Carolina are at a VERY HIGH risk of being infected, whether they live indoors or out. In fact, our state has the 3rd highest number of reported heartworm cases in the United States. _________________________________________________________________________________

ALL dogs should be tested for heartworms every year. A monthly prevention medication to prevent them from this DEADLY parasite is a MUST. Remember that if your dog is infected with heartworms, treatment is both dangerous and expensive.

"An ounce of prevention is worth a pound of cure."

1910 N. Church St. Suite E Greensboro, NC 27405 336.333.5336 fax: 336.333.5166

THERE IS A HIDDEN KILLER IN NORTH CAROLINA. 240,000 DOGS AND CATS ARE DIAGNOSED WITH HEARTWORMS EVERY YEAR.

HAS YOUR PET BEEN TESTED?

CANINE ONLY

We offer CANINE HEARTWORM TESTING for ONLY $25.00 at time of surgery!!!

Would you like for your dog to be tested for heartworm infection today for an additional cost of ONLY $25.00?

YES

NO

CANINE AND FELINE

Would you like to purchase a monthly heartworm medication to PREVENT your

dog or cat from getting heartworm disease and intestinal worms?

YES! (Please select a package size.)

6-month supply 12-month supply

Interceptor Plus

Heartgard Plus

Sentinel Spectrum

NO

SIGNED_________________________________________________ DATE_____________________

1910 N. CHURCH ST. SUITE E. GREENSBORO, NC 27405 336.333.5336 (FAX) 336.217.8227

Dangers of Fleas & Ticks

Fleas

Fleas can be carriers of worms and diseases. In some cases pets can be allergic. For instance- flea saliva is one of the most allergenic substances known to man. One in ten cats and dogs will suffer from a skin condition known as Flea-Allergy Dermatitis. This is a direct result of their sensitivity to flea bites. The symptoms of flea allergies are major skin irritation and hair loss. All it takes is one bite for an allergic reaction to occur. Repeated flea bites not only cause discomfort for your petsheavy infestations can lead to iron deficiency and even death in very young puppies and kittens.

Ticks

Ticks can directly cause illness and disease in you and your pet. Some examples are Lyme disease and Rocky Mountain Spotted Fever. Lyme disease is spreading rapidly. North Carolina has multiple reported cases of both Lyme disease and Rocky Mountain Spotted Fever. It's risky to allow these pests to hitch rides on the family pet.

Fleas are a Nuisance, Ticks Carry the Diseases

_____________________________________________________________________________

We recommend all pets go home on flea/tick preventative.

Would you like to purchase a monthly flea/tick medication to PREVENT pet from getting fleas and/or ticks?

YES

No

_____________________________________________________________________________

Frontline Gold single dose

3 pack

6 pack

Effitix

single dose

3 pack

6 pack

Nexgard

single dose

3 pack

6 pack

Credelio

single dose

3 pack

6 pack

_____________________________________________________________________________

SIGNED_________________________________________ DATE_________________________

1910 CHURCH ST. SUITE E. GREENSBORO, NC 27405 336.333.5336 (FAX)336.217.8227

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