Original Medical Record Template
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2Margaret McAllister Brock Veterinary Clinic
1521 W. Dobbins Rd, Phoenix AZ 85041
(602) 997-7586 Opt. 4
ORIGINAL MEDICAL RECORD
(Apellido)
(Nombre)
Last Name
: _______________ First Name
: ___________________
(Dirección)
Address
:_______________________________________________
(Ciudad)
(Código Postal)
City
:__________________ State:____ Zip
:_______
(Teléfono)
(Tele. Alterno)
Phone
:(
)_____________Alternate Phone
: (
)____________
(Correo Electronica)
Email address
: ___________________________________
(Nombre)
(Raza)
Name
: _________________ Breed
:________________ Color:____________
(Perro)
(Gato)
Dog
Cat
Primarily Indoor
Outdoor
Male (M)
Female (H) Spayed or Neutered (Fixed)
Yes
No
(Edad)
(Años)
(Meses)
Age
: _______ Years
_______ Months
or Date of Birth _________
How did you hear about us? ______________________________________________
Dog Vaccines - $20
Preventatives
Miscellaneous
Rabies
1 Yr
3 Yr
Tri-Heart Plus – 6 mo. Supply
Microchip
$35
st
nd
rd
DA
PP
1
2
3
(Heartworm Preventative)
Cat Carrier
$6
2
th
“4-in-1”
4
Annual
Up to 25 lbs (Blue)
$24
Dewormer
$12
Bordetella
26-50 lbs (Green)
$32
Nail Trim
$17
Cat Vaccines - $20
51-100 lbs (Brown)
$37
st
nd
FVRCP
1
2
Annual
Vectra 1 mo/6 mo
st
FeLV
1
Annual
2Yr
(Flea/Tick Prev)
Office Visit
$24
Rabies
1 Yr
3 Yr
-Dogs
1 mo.
6 mo.
5-10lbs
$12
$70
Tests
11-20lbs
$13
$72
PVP1
$35
FeLV/FIV Test
$39
21-55 lbs
$15
$84
Heartworm Test
$30
. 56-95 lbs
$17
$86.
KVP1
$27
4DX Test
$39
.
(Combo Test for Heartworm, Lyme Disease &
-Cats 1 mo. 6 mo.
Ehrlichia Canis,Anaplasma)
$13
$73
Total Estimate $______
_________
Owner’s Initials
FOR OFFICE USE ONLY
Vitals:
Test Results
Vaccinations
Temperature: _______
FeLV/FIV Test ______
Rabies (Pfizer – Nobivac 3- Killed)________
Pulse: ________
Heartworm Test _____
Exp: _________
Lot#: _________
Respirations:________
4DX _______________
DA
PP _________
FVRCP _________
2
Home Again #
Lot #
Weight: _________
Bordetella _________
FeLV _________
Tech_________
Pyrantel Pamoate (50 mg/ml): ___________ mls
1. General Appearance
2. Oral Cavity/Teeth
3. Mucous Membrane
4. Eyes
NORM
ABN
N/E
NORM
ABN
N/E
NORM
ABN
N/E
NORM
ABN
N/E
5. Ears
6. Heart
7. Respiratory
8. Abdomen
NORM
ABN
N/E
NORM
ABN
N/E
NORM
ABN
N/E
NORM
ABN
N/E
9. Musculoskeletal
10. Lymph Nodes
11. Genitourinary
12. Integumentary
NORM
ABN
N/E
NORM
ABN
N/E
NORM
ABN
N/E
NORM
ABN
N/E
Appears healthy for vaccination
Decline for vaccinations
Pain Y / N
Score__________
Notes_____________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________Veterinarian
Date
_______________________
___________
Check In Time:__________ Entered:__________ Check Out Time:__________
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