Date of Appointment: (required)
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Disease Risk Assessment Form for (Pet's Name): (required) When your pet goes outdoors, is it ever unsupervised? (Outdoor time counts as unsupervised any time a human isn’t present, even if the pet is fenced in or leashed.) (required) Do you have a fenced yard or invisible fence? (required) Does your pet come into contact with other pets or their environments? (required) Is there wildlife in your area (mice, squirrels, birds, opossums, raccoons, skunks, etc)? (required) Have you seen ticks on yourself or your pet, or in areas you frequent with your pet? (required) Does your pet have any opportunity to drink from standing water (ponds, puddles, etc) outdoors? (required) Does your pet sleep with you or your children? (required) Do you ever take your pet to a groomer or boarding facility? (required) Do you ever take your pet to cat or dog shows? (required) If you own a dog, do you ever take it hunting? (required) Does your cat hunt? (required) Do you travel with your pet? (required) If your pet is on a monthly heartworm preventative, have you ever missed a dose by more than two weeks? (required) If your pet is on a monthly tick control product, have you ever been late to apply it, missed a dose, or skipped a month? (required) What tick control product do you use? (required) Today's Date: (required)
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