Administrative Hours: 8:30 am - 6:30 pm, Wednesday - Saturday | 6225 42nd Ave. N., Minneapolis, MN 55422
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Preventative Care Clinic Exam Forms
Preventative Care Exam Form
Pet Name - Reference ID
(Required)
Approved Services and Medications
Approved Services
Healthy Pet Exam
Dental Quote
Dental Assessment
Spay/Neuter Assessment
Geriatric Assessment
Microchip
Other
Approved Tests
Heartworm Snap Test
4Dx Snap Test
Feline Triple Snap
Healthcheck
Healthcheck Plus
Preanesthetic Panel
Fecal Test
Other
Approved Vaccinations
Canine Rabies Booster
Canine Rabies 1 Yr
Canine Rabies 3 Yr
DHPP Booster
DHPP 1 Yr
DHPP 3 Yr
Bordetella
Leptospirosis Booster
Leptospirosis 1 Yr
Lyme Booster
Lyme 1 Yr
Feline Rabies Booster
Feline Rabies 1 Yr
Feline Rabies 3 Yr
Feline Distemper Booster
Feline Distemper 1 Yr
Feline Distemper 3 Yr
FeLv Booster
FeLv 1 Yr
Other
Approved Medications
Heartgard Plus Blue Up to 25#
FREE DOSE: Heartgard Plus Blue Up to 25#
Heartgard Plus Green 26-50#
FREE DOSE: Heartgard Plus Green 26-50#
Heartgard Plus Brown 51-100#
FREE DOSE: Heartgard Plus Brown 51-100#
Nexgard Orange 4-10#
FREE DOSE: Nexgard Orange 4-10#
Nexgard Blue 10.1-24#
FREE DOSE: Nexgard Blue 10.1-24#
Nexgard Purple 24.1-60#
FREE DOSE: Nexgard Purple 24.1-60#
Nexgard Red 60.1-121#
FREE DOSE: Nexgard Red 60.1-121#
Revolution Puppy and Kitten
Revolution Plus Feline 2.8-5.5#
Revolution Plus Feline 5.6-11#
Revolution Plus Feline 11.1-22#
Panacur Granules 222 mg/g
Pyrantel Pamoate 50 mg/ml
Metronidazole 50 mg/Tablet
Metronidazole 250 mg Tablets
Metronidazole 500 mg Tablets
Gabapentin 100 mg Capsules
Gabapentin 300 mg Capsules
Gabapentin 400 mg Capsules
Gabapentin oral liquid 50 mg/ml
Trazodone 50 mg Tablet
Trazodone 100 mg tablets
Written Prescription
Other
Other Approved Test, Service, or Vaccination
Client Forgoes
Dental Quote
Dental Assessment
Spay/Neuter Assessment
Geriatric Assessment
Microchip
Heartworm Snap Test
4Dx Snap Test
Healthcheck
Healthcheck Plus
Preanesthetic Panel
Fecal Test
Canine Rabies Vaccine
DHPP Vaccine
Bordetella Vaccine
Leptospirosis Vaccine
Lyme Vaccine
Feline Rabies Vaccine
Feline Distemper Vaccine
FeLv Vaccine
Heartgard
Nexgard
Revolution
Panacur
Pyrantel
Metronidazole
Gabapentin
Trazodone
Other
Heartgard Plus Blue Up to 25#
Heartgard Plus Blue Up to 25#: Give 1 tablet by mouth once a month to prevent heartworm disease. Recommend annual heartworm testing. Qty #1 tablet. Refills: 0 Rx Exp: 12 months
FREE DOSE: Heartgard Plus Blue Up to 25#
Heartgard Plus Blue Up to 25#: Give 1 tablet by mouth once a month to prevent heartworm disease. Recommend annual heartworm testing. Qty #1 tablet. Refills: 0 Rx Exp: 12 months
Heartgard Plus Green 26-50#
Heartgard Plus Green 26-50#: Give 1 tablet by mouth once a month to prevent heartworm disease. Recommend annual heartworm testing. Qty #1 tablet. Refills: 0 Rx Exp: 12 months
FREE DOSE: Heartgard Plus Green 26-50#
FREE DOSE: Heartgard Plus Green 26-50#: Give 1 tablet by mouth once a month to prevent heartworm disease. Recommend annual heartworm testing. Qty #1 tablet. Refills: 0 Rx Exp: 12 months
Heartgard Plus Brown 51-100#
Heartgard Plus Brown 51-100#: Give 1 tablet by mouth once a month to prevent heartworm disease. Recommend annual heartworm testing. Qty #1 tablet. Refills: 0 Rx Exp: 12 months
FREE DOSE: Heartgard Plus Brown 51-100#
FREE DOSE: Heartgard Plus Brown 51-100#: Give 1 tablet by mouth once a month to prevent heartworm disease. Recommend annual heartworm testing. Qty #1 tablet. Refills: 0 Rx Exp: 12 months
Nexgard Orange 4-10#
Nexgard Orange 4-10 #: Give 1 chewable once a month for flea and tick prevention. For dogs and puppies 8 weeks and older. Qty #1 chewable tablet. Refills: 0 Exp: 12 months
FREE DOSE: Nexgard Orange 4-10#
FREE DOSE: Nexgard Orange 4-10 #: Give 1 chewable once a month for flea and tick prevention. For dogs and puppies 8 weeks and older. Qty #1 chewable tablet. Refills: 0 Exp: 12 months
Nexgard Blue 10.1-24#
Nexgard Blue 10.1-24#: Give 1 chewable once a month for flea and tick prevention. For dogs and puppies 8 weeks and older. Qty #1 chewable tablet. Refills: 0 Exp: 12 months
FREE DOSE: Nexgard Blue 10.1-24#
FREE DOSE: Nexgard Blue 10.1-24#: Give 1 chewable once a month for flea and tick prevention. For dogs and puppies 8 weeks and older. Qty #1 chewable tablet. Refills: 0 Exp: 12 months
Nexgard Purple 24.1-60#
Nexgard Purple 24.1-60#: Give 1 chewable once a month for flea and tick prevention. For dogs and puppies 8 weeks and older. Qty #1 chewable tablet. Refills: 0 Exp: 12 months
FREE DOSE: Nexgard Purple 24.1-60#
FREE DOSE: Nexgard Purple 24.1-60#: Give 1 chewable once a month for flea and tick prevention. For dogs and puppies 8 weeks and older. Qty #1 chewable tablet. Refills: 0 Exp: 12 months
Nexgard Red 60.1-121#
Nexgard Red 60.1-121 #: Give 1 chewable once a month for flea and tick prevention. For dogs and puppies 8 weeks and older. Qty #1 chewable tablet. Refills: 0 Exp: 12 months
FREE DOSE: Nexgard Red 60.1-121#
FREE DOSE: Nexgard Red 60.1-121 #: Give 1 chewable once a month for flea and tick prevention. For dogs and puppies 8 weeks and older. Qty #1 chewable tablet. Refills: 0 Exp: 12 months
Revolution Puppy and Kitten
Revolution Puppy and Kitten: Part fur between the shoulder blades, apply contents of tube to skin. Do not bathe pet 2 days prior or 2 days after applying medication. Qty #1 tube. Refills: 11. Exp: 12 months
Revolution Plus Feline 2.8-5.5#
Revolution Plus Feline 2.8-5.5#: Part fur between shoulder blades and apply contents of 1 tube to skin once a month to prevent flea infestation. Qty #1 tube. Refills: 11. Exp: 12 months
Revolution Plus Feline 5.6-11#
Revolution Plus Feline 5.6-11#: Part fur between shoulder blades and apply contents of 1 tube to skin once a month to prevent flea infestation. Qty #1 tube. Refills: 11. Exp: 12 months
Revolution Plus Feline 11.1-22#
Revolution Plus Feline 11.1-22#: Part fur between shoulder blades and apply contents of 1 tube to skin once a month to prevent flea infestation. Qty #1 tube. Refills: 11. Exp: 12 months
Panacur Granules 222 mg/g
Panacur Granules 222 mg/g: Sprinkle contents of 1 bag (**g) on food once a day for 3 days. Qty #20 grams. Refills: 0 Exp: 6 months
Pyrantel Pamoate 50 mg/ml
Pyrantel Pamoate 50 mg/ml: ** Qty #5 mLs. Refills: 0 Exp: 6 months
Metronidazole 50 mg/Tablet
Metronidazole 50 mg Tablets: Give 1 tablet by mouth once every 12 hours for 5 days. Qty #10 tablets. Refills: 0 Exp: 6 months
Metronidazole 250 mg Tablets
Metronidazole 250 mg Tablets: Give 1 tablet by mouth once every 12 hours for 5 days. Qty #10 tablets. Refills: 0 Exp: 6 months
Metronidazole 500 mg Tablets
Metronidazole 500 mg Tablets: Give 1 tablet by mouth once every 12 hours for 5 days. Qty #10 tablets. Refills: 0 Exp: 6 months
Gabapentin 100 mg Capsules
Gabapentin 100 mg Capsules: Give * tablet the night before and * tablet 2 hours before a stressful event. Qty #10 tablets. Refills: 0 Exp: 6 months
Gabapentin 300 mg Capsules
Gabapentin 300 mg Capsules: Give * tablet the night before and * tablet 2 hours before a stressful event. Qty #10 tablets. Refills: 0 Exp: 6 months
Gabapentin 400 mg Capsules
Gabapentin 400 mg Capsules: Give * tablet the night before and * tablet 2 hours before a stressful event. Qty #10 tablets. Refills: 0 Exp: 6 months
Gabapentin oral liquid 50 mg/ml
Gabapentin oral liquid 50 mg/ml: Give * mL the night before and * mL 2 hours before a stressful event. Qty #10 mL. Refills: 0 Exp: 6 months
Trazodone 50 mg Tablet
Trazodone 50mg Tablet: Give * tablet the night before and * tablet 2 hours before a stressful event. Qty #10 Tablets Refills: 0 Exp: 6 months
Trazodone 100 mg Tablet
Trazodone 100mg Tablet: Give * tablet the night before and * tablet 2 hours before a stressful event. Qty #10 Tablets Refills: 0 Exp: 6 months
Written Prescription
Medication Name: Directions Qty #* Tablets Refills: 0 Exp: 6 months
Other
Medication Name: Directions Qty #* Tablets Refills: 0 Exp: 6 months
Exam Notes
Weight
Assessed
Estimate
Not Assessed
Unable to Obtain
Patient Weight in Lbs
Temperature
Assessed
Unable to Obtain
Not Assessed
Temperature
Heart Rate
Assessed
Unable to Obtain
Not Assessed
Heart Rate
Respiratory Rate
Assessed
Unable to Obtain
Not Assessed
Respiratory Rate
Mucus Membrane
Assessed
Unable to Obtain
Not Assessed
Mucus Membrane
CRT
Assessed
Unable to Obtain
Not Assessed
CRT
Hydration
Assessed
Unable to Obtain
Not Assessed
Hydration
Body Condition Score
Not Assessed
1/9
2/9
3/9
4/9
5/9
6/9
7/9
8/9
9/9
Body Condition Comments
FAS Score
Not Assessed
0/5
1/5
2/5
3/5
4/5
5/5
FAS Comments
Eyes
NSF
AbN
Not Assessed
Eyes Comments
Ears
NSF
AbN
Not Assessed
Ears Comments
Integ
NSF
AbN
Not Assessed
Integ Comments
Resp
NSF
AbN
Not Assessed
Resp Comments
Oral
NSF
AbN
Not Assessed
Oral Comments
CV
NSF
AbN
Not Assessed
CV Comments
AbN Dental Issue
Dental Score: Level 1/5
Dental Score: Level 2/5
Dental Score: Level 3/5
Dental Score: Level 4/5
Dental Score: Level 5/5
Retained Teeth
Gum Recession
Dental Tarter
Gingivitis
Loose Teeth
Fractured/Broken Teeth
CV Issue
1/6 Heart Murmur
2/6 Heart Murmur
3/6 Heart Murmur
4/6 Heart Murmur
5/6 Heart Murmur
6/6 Heart Murmur
Incidental finding, please follow up with your family veterinarian or a cardiologist.
ABD
NSF
AbN
Not Assessed
ABD Comments
PLN/THYROID
NSF
AbN
Not Assessed
PLN/THYROID Comments
MS
NSF
AbN
Not Assessed
MS Comments
UROGEN
NSF
AbN
Not Assessed
UROGEN Comments
NEURO
NSF
AbN
Not Assessed
NEURO Comments
Digital Rectal
NSF
AbN
Not Assessed
Digital Rectal Comments
Significant Exam Findings
No concerns noted on remainder of exam
Pet is ineligible to receive vaccines today
The following should be evaluated by a veterinarian:
Other
Exam Notes/Take Home Notes
Test Results
Results Received: Pending Tests:
Follow Up Directions
N/A
Eligible to Schedule Dental
Eligible to Schedule Spay/Neuter
Recommend Urgent Care Exam or Exam with Family Veterinarian
Return for Preoperative Exam and Bloodwork to Schedule
Other
Additional Follow Up Directions
In Clinic Only Visit Notes
Overseeing DVM
EMG
WKG
CVT
LT
BD
AMT
ET
LSL
VA/VT
KJ
HP
JJ
RH
PTL
AMT
ET
BD
LT
CAN
LSL
CW
Record Complete
(Required)
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