Client InformationClient Name Email address Client Address Phone Risk AssessmentCat's Name Cat's Age Number of cats in household Does your cat go outdoors? Yes No If so, is the cat supervised while outdoors? Yes No Does your cat come into contact with other cats' environments, including stray animals? Yes No Is there wildlife in your area, including mice, squirrels, birds, possums, racoons, skunks or deer? Yes No Have you found ticks on your pets or are there ticks in your area? Yes No Do you travel with your cat to areas where ticks or mosquitoes may be present? Yes No If you do, do you travel through the Southeastern U.S.? Yes No Have all cats in the household been tested for Feline Leukemia? Yes No Have all cats in the household been tested for Feline Immunodeficiency Virus (FIV)? * Yes No Did any cats test positive for either virus? Yes No Does your cat sleep with you or your children? Yes No Do you plan to acquire another cat in the future? Yes No Do you work with or handle stray or unvaccinated cats? Yes No Do you ever take your cat to a groomer, boarding facility, pet store or shows? Yes No Does this cat get into fights with other cats or has he/she had a bite wound abscess? Yes No Is your pet spayed or neutered? Yes No Are there mosquitoes in your area? Yes No Do you live near water? Yes No Is your cat on monthly heartworm preventative? Yes No Is anyone in your household immuno-compromised? Yes No
