Annual Wellness Form

Save time at your next appointment! Please complete your required Annual Wellness Form online from any device at any time before your visit.

Get Started

Annual Wellness Form

Please complete this form completely and accurately so that we can get to know you and your pet(s) before your visit. If this is an emergency or your pet requires immediate attention, please call us at 240-715-6570 for a faster response.

Name *

First

Last

Phone *

Email *

Pet Name *

Is this your pet's first visit with us? *

* If this will be your pet’s first visit, please use the Initial Intake form.

What wellness/preventative care services are you interested in today? *

Infectious disease screening (4dx, FeLV, FIV)
Wellness screening blood work
Fecal
Microchip placement
Nutrition counseling
Titer/Vaccination
Other

If 'Other', please specify: *

Has your pet ever had an adverse reaction to drugs, supplements, or vaccines? *

If your pet has adverse reactions to vaccinations, have you already given an antihistamine before today's appointment? *

Yes
No
Other

If 'Other', please specify: *

Is your pet currently receiving any parasite preventatives (i.e. heartworm, flea/tick)? *

What heartworm and/or flea and tick prevention is your pet on? *

Interceptor
Interceptor Plus
Heartgard Plus
Seresto
Bravecto
Credelio
My pet is NOT currently on heartworm prevention
My pet is NOT currently on flea/tick prevention
Other

If 'Other', please specify: *

Will you need a refill of preventatives for your pet? *

If yes, what preventatives will you need a refill of? *

Interceptor Plus
Heartgard Plus
Seresto Collar
Credelio
Bravecto
Revolution
Written script (please provide choice under "Other")
Other

What do you feed your pet and how much? *

Does your pet have any chronic or recurring problems, injuries or illnesses? *

If yes, what is your pet's chronic or recurring condition *

Is your pet currently on any prescription medications or supplements? *

If yes, what medications or supplements does your pet receive? How much do you give and how often are they given? *

Environmental / Lifestyle

Does your pet...

Travel with you out of state
Go to dog parks
Go hiking or swimming
Have free access to the outdoors
Only walk on a leash
Go to a boarding facility
Go to the groomers
Hunt prey (cats)
Indoor only (cats)

Medical Concerns

Do you have any concerns that you would like to address with the doctor? *

Changes in mobility
Changes in thirst or urination
Weight gain or weight loss
Changes in appetite
Itchiness or skin condition
Vomiting, soft stool/diarrhea
Coughing, gagging, or sneezing
Decreased energy level or loss of interest in normal activities
Bad breath or bleeding gums
House-soiling
I have no concerns with my pet
Other

If 'Other', please specify: *

Is there anything else you would like us to know and/or do you have any questions?

Cancellation Policy

I acknowledge and agree to comply with the cancellation policy, If you do not show up for your scheduled appointment, and you have not notified us at least 24 hours in advance, you will be required to pay a missed appointment fee of $100. The missed appointment fee for any surgical or dental procedure is $275.

Signature *

Date *

Name

Ready For A Visit?

We proudly serve the pets of Germantown, Maryland, Northern Virginia, Philadelphia, Richmond, Washington, DC, and much of the east coast. We look forward to seeing you and your pet! Call to schedule an appointment today!

Call for an Appointment

Questions?

Get in touch! We look forward to hearing from you.



Location

Germantown Square Shopping
Center, Lower Level
12627 Wisteria Drive
Suite C & D
Germantown, MD 20874



Hours

Mon-Wed-Fri: 10:00 AM – 6:00 PM
Tue: 10:00 AM – 5:00 PM
(Not Seeing Patients)
Thu: 10:00 AM – 4:30 PM
Sat: 9:00 AM – 3:30 PM
Sun: Closed



Contact Information

Phone: 240-715-6570
Fax: 240-715-6574
E: holvethealing@gmail.com

Read our most recent newsletter!

Newsletter

Subscribe to our Newsletter

To subscribe to our newsletter, please click here and fill out the form.