Client name Patient name PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Thank you for choosing East Maiden Animal Clinic to care for your pet(s)! Before coming in for your visit, we would like to go over some information with you. Please review and answer the following questions. 1. 4DX Test • We recommend all dogs be tested yearly for lyme disease due to the high prevalence of this disease seen in Pennsylvania. As of 2021, the lyme prevalence in Washington and Allegheny county is around 13% (13 out of 100 tested dogs are lyme positive). The lyme test also looks for other less prevalent diseases, such as heartworm disease, anapalsma, and ehrlichia. • Currently, lyme disease is not believed to affect cats. Because of this, we do not recommend testings cats for lyme disease. Yes, please test my dog for lyme disease if they haven’t been tested within the year (Cost $53.30) Check Here I am not interested in having my dog tested for lyme disease todayI will need to sign the following waiver - Click Here Check Here 2. General Bloodwork • As our pets age, it is important to monitor their health both on the outside and inside. While a good physical examination can reveal many potential problems, some diseases (such as early kidney or thyroid disease) can be detected much earlier through bloodwork. When caught early, we can better help manage these diseases to help provide for better, longer care of your pet. Because of this, having yearly bloodwork performed is recommended, especially in older pets (over 7 years of age). Yes, Please send out a blood panel today (Cost $150.00) Check Here I am not interested in having a blood panel sent out during today’s visit Check Here 3. Do you need any refills? 4. What current issues do you want to go over with the doctor? 5. Would you like your pet’s nails trimmed for an additional fee of $10? Yes No 5. We encourage you to download the PetPro Connect App. This app allows you to see which vaccines your pet(s) are due for and which medications they are currently on. Additionally, you may request appointments through the app and can also use the chat feature to message with a member of our staff. For more information please click here Thank you for choosing us for your veterinary needs! Please do not hesitate to ask us about any of these options prior to your visit. This form is meant to make sure we cover all of your concerns (and ours) during your visit! See you soon!CAPTCHA