Pets and Peopletm Visiting Society

Pets and People®Visiting Society

Veterinary Inspection and Medical Record

This form must be completed annually after acceptance into the program.

Please complete both pages of this form. Return completed forms to:

Pets and People Visiting Society

c/o Susan Shanks

3285 O’Reilly Court

Kelowna, B.C. V1W 2V6

OWNER INFORMATION

Name:

Address:Postal code:

Telephone:(home)(business)(other)

Email:Fax:

PET INFORMATION

Pet’s name:Age:Sex:

Species:Breed:

Description:Weight:

Do you ever feed your pet raw meat or bones?

VETERINARY FACILITY

Name:

Address:Postal code:

Phone:Fax:

Email:

OWNER’S ABILITY TO HANDLE/CONTROL PET

Comments:______

MEDICAL HISTORY

Are there any ongoing medical problems requiring medication?ٱ Yesٱ No

If yes, please describe:

PHYSICAL EXAMINATION

Any problems with cleanliness, grooming?ٱ Yesٱ No

Any discharges/weeping (eyes, ears, nose, mouth, genitals, anal area, feet)?ٱ Yesٱ No

Any dental disease (tartar, gingivitis, periodontitis)?ٱ Yesٱ No

Any possible painful conditions that may cause the pet to react suddenly to handling (arthritis, otitis, eye problems, etc.)?

ٱ Yesٱ No Any coughing or diarrhea?ٱ Yesٱ No

If yes to any of these, please comment:

BEHAVIOR

Any behavioural problems you are aware of?ٱ Yesٱ No

Does the pet react adversely to handling and manipulation during the exam (feet, head, mouth, ears and tail)?

ٱ Yesٱ No

If yes to either of the above, please comment:

VACCINATIONS

Type:Date:

Note: A wellness examand fecal are required prior to acceptance into Pets and People. An annual wellness check is required and subseqent fecal testsare at the discretion of your veterinarian. Rabies is required for both dogs and cats according to label recommendations (vaccinated at one year of age, then every three years). The DA2P-CPV* for dogs and FVRCP** for cats may be done at the discretion of the pet’s veterinarian.

PARASITE CONTROL

Fecal Analysis (annual)Date:

Type of test(s) and results:

Heartworm Testing and Prevention

(Recommended for Pets and People but not essential, depending on veterinarian’s assessment of risk factors.)

Date of last test:Prevention product used:

Prevention considered necessary at this time?ٱ Yesٱ NoPrevention declined

Any external parasites (fleas, ticks, mites, lice, dermatophytes)?ٱ Yesٱ No

If yes, please describe

Date:Veterinarian’s Signature

Veterinarian’s Name (please print)

*Distemper, Hepatitis, Parainfluenza and Canine Parvovirus **Feline Viral Rhinotracheitis, Calcivirus and Panleukopenia