Bravecto® Quantum Form – Lodi Animal Hospital
Lodi Animal Hospital
Bravecto Quantum Suitability Assessment Questionnaire
Bravecto Quantum is an injection that provides flea and tick protection for dogs for 1 year*.
Instructions: Please answer all questions below to determine if Bravecto Quantum is appropriate for your dog.
Basic Eligibility
1. Is your dog younger than 6 months?
Yes = ❌Not eligible
2. Does your dog weigh less than 2.2 pounds?
Yes = ⚠️Requires veterinary consultation
3. Has it been over 6 months since your dog was examined by a veterinarian at our hospital?
Yes = ⚠️Requires veterinary consultation
Medical History
4. Has your dog ever had a seizure or is on anti-seizure medication?
Yes = ⚠️Requires veterinary consultation
5. Has your dog been diagnosed with any neurological disorder (epilepsy, brain tumor, etc.)?
Yes = ⚠️Requires veterinary consultation
6. Has your dog ever experienced tremors or loss of coordination (ataxia)?
Yes = ⚠️Requires veterinary consultation
7. Has your dog ever had an adverse reaction to any flea/tick medication including oral or topical Bravecto?
Yes = ⚠️Requires veterinary consultation
8. Has your dog ever had an allergic reaction (hives, facial swelling, difficulty breathing) to any medication, vaccine, or medical treatment?
Yes = ⚠️Requires veterinary consultation
Current Health
9. Do you have concerns about your dog's current health or medical condition(s)?
Yes = ⚠️Requires veterinary consultation
10. Have there been changes to your dog’s appetite and energy levels recently?
Yes = ⚠️Requires veterinary consultation
Female Reproductive Status
11. Is your dog currently pregnant, nursing, or planned for breeding in the next 12 months?
Yes = ❌Not eligible
Lifestyle & Exposure
12. Does your dog travel to areas where lone star ticks (Amblyomma americanum) are common ie: Midwestern, southeastern, and eastern US?
*Bravecto Quantum is indicated to protect against Amblyomma americanum for 8 months.
Yes = ⚠️Requires veterinary consultation
If you answered ‘yes’ to any above questions, please contact us to schedule an exam to assess and further discuss eligibility.
If you answered ‘no’ to all questions above, please email this completed questionnaire to [email protected] and schedule an appointment for the Bravecto Quantum injection with a veterinary assistant or a veterinary technician.
Owner Certification
I certify that the answers provided above are accurate to my dog’s current health status. I understand the risks and benefits of Bravecto Quantum and waive a full veterinary exam for the purpose of receiving this injection today.
Signature (printed name/sign):
Date:
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About Lodi Animal Hospital
Animal Hospital, Lodi is Lodi, California’s leading veterinary facility, providing routine and advanced care for your pets. Our team of doctors, veterinary assistants and support staff are dedicated to the best possible outcomes for our patients, utilizing the latest veterinary medical technology and techniques.
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