INITIAL HEALTH EVALUATION OF RESCUE SCOTTISH TERRIER

Veterinary Hospital Name & Address :

Rescue Organization:__________________________________________________

Rescue Representative Name:___________________________________________

Address:_________________________

City:_____________________________

Phone:____________________________

Date of exam:______________,19___

Attending Veterinarian: (Please Print)____________________________________

Breed: _________________ Sex:___Neut?:_____Age:_____Height:____Weight:___

Breeder:_____________________________Tattoo # (if any):___________________

Microchip:______________________________

Findings of initial visit:________________________________________________

__________________________________________________________________________

Vaccinations anticipated:__________________________________________________

Worming program needed:___________________________________________________

Heartworm Medication needed:______________________________________________

Is this animal neutered/spayed?:________________Was this animal X-rayed?_________

If so, for what?__________________________________________________________

__________________________________________________________________________

Comments/Suggestions:_____________________________________________________

__________________________________________________________________________

Attending Veterinarian's Signature:_______________________________________

Thank you for your help and time. Please return this form to us at the

address below: (your agency's address)