Vet Check Form
A copy of the form will be sent to the interviewer.
Date of call:
Name(s) of Applicant(s):
WHICH STATE SHOULD RECEIVE THIS FORM?
This is the same team that assigned you the application.
TESTING (Interviewer will receive copy)
Name of Vet Practice
Person providing the information and their position:
How long have the applicant been your client?
Names / types / ages of pets currently on record:
Interviewer: Please review the list of current pets listed in the application/interview with the person on the phone. Are all animals listed at this office? Did we find new ones that were not listed? If so, list here so we can follow up on the phone interview.
Are the current pets all spayed/neutered?
Were past pets all spayed/neutered?
Spay/neuter comments if needed.
Has the client ever brought in a pet with unexplained injury or signs of neglect or other concerning problems?
Are there any unusual or early deaths?
If yes, please describe.
Has the client ever declined care due to cost?
If yes, please describe.
Does/did the client bring their pets in for wellness visits at least once a year AND vaccinate according to the vet’s recommendations?
Any miscellaneous comments about above responses.
Heartworm testing and meds
We are trying to be sure there is evidence of continuous administration of heartworm prevention.
When was the last heartworm test?
Have all tests been negative over time?
Does the client purchase heartworm meds from the practice or receive a prescription?
Has purchased it at the practice
Has been given a prescription
Has done both
Neither. No history of using heartworm preventative.
If purchased, WHEN was the last purchase and HOW MANY MONTHS were purchased?
How about the purchase prior to that?
If they received a prescription, WHEN was the last one? HOW MANY MONTHS were written? How about PRIOR RX?
Heartworm preventative is very important to us! Does the client seem to provide this consistently over time to all pets?
Would you recommend this client as an ESRA adopter or foster home?
Any additional comments and impressions:
Any troubles with the form? Any feedback on the form?
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