Name

First Last

Phone

Email

Pet's Name

Species

Breed

How old is your pet?*

Where do you live?*

How many dogs do you own?*

How many cats do you own?*

How many other pets do you own?*

Does your pet go outside?*

Yes
No

Is your pet supervised or unsupervised when outside?*

Supervised
Unsupervised

Does your pet hunt or do fieldwork?*

Yes
No

Do you take your pet camping?*

Yes
No

Do you take your pet to forest preserves or dog parks?*

Yes
No

Do you take your pet for walks?*

Yes, leashed
Yes, off leash
No

Do other people ever bring their pets to your house?*

Yes
No

Does your pet come in contact with other animals?*

Yes
No

Are there mosquitos and/or ticks in your area?*

Yes
No

Do you travel with your pet?*

Yes
No

Do you take your pet to the groomer?*

Yes
No

Do you take your pet to a pet superstore (Petco/Petsmart)?*

Yes
No

Do you board your pet at a boarding facility?*

Yes
No

Do you take your pet to dog or cat shows?*

Yes
No

Is your pet spayed or neutered?*

Yes
No

Does your pet ever drink from standing water outdoors (ponds, puddles...)?*

Yes
No

Is your dog or cat on a monthly heartworm preventative?*

Yes
No

Have you ever missed a dose by more than 2 weeks?

Yes
No

Do you ever have wild animals in your yard?*

Yes
No

Is your pet strictly indoors and never comes into contact with other animals?*

Yes
No

Disease Risk Assessment Form

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Sutton Road Animal Hospital

Hours

Emergency