Vet Check Questionnaire

Coordinator: *

Date: *

Applicant Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address

Vet Clinic Information

Vet Clinic Name *

Name of Vet

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

How long with this vet? *

Name and type of pet(s) listed at vet's office: *

Last Vet visit and reason? *

Spayed/Neutered (all)? *

Date of Last Annual Exam? *

Date of last vaccinations? *

Dogs current on Heartworm Preventative? *

Yes

No

N/A

Any pets that have died? *

If Yes, of what?

If Yes, what was done to extend life or to make things easier for the pet?

Any comments from the vet or clinic that are pertinent?

Additional comments/observations

Name of Interviewer: *

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