1642 Hwy 160 West, Suite 104
Fort Mill, SC 29708
(803) 547-8387
www.baxtervet.com
Annual Pet Lifestyle Questionnaire
Your Full Name
Your Pet's Name
What is your pet’s current diet
How much time does your pet spend outdoors?
100%
50%
25%
Only if they escape
Does your pet visit areas that are inhabited by wildlife
Yes
No
Do you bring your pet to different parts of the country frequently?
Yes
No
List of places most visited:
Does your pet interact with children under the age of 5?
Yes
No
Does your pet board, show, attend daycare or the dog park, or go to the groomer?
Yes
No
List the name of the places your pet visits:
Do you foster animals or plan to acquire a new animal in your home this year?
Yes
No
Would you be interested in a FREE 1-month trial of Trupanion Pet Insurance? (Valid for healthy pets ages 8 weeks to 13 years. Offer expires after 1 month
Yes
No
In the event of a life threatening emergency, would you allow CPR to be performed on your pet?
Yes
No
Is your pet taking any medications, supplements, or monthly heartworm/flea prevention?
Yes
No
If applicable, list the dose and frequency of each medication:
List any refills needed today:
Please list any specific concerns you may have or additional services needed (e.g., nail trim):
Submit
Should be Empty: