C10000643 / invoice 10000

Annual Vaccination
Booking Notes: Vaccination due 
Pet Insurance Provider & Policy No (if applicable & not provided): PIA PI07332086
Person (Gustavo)
Insurance (GAP) 
Preventatives ()

Vaccination & Health Check

**HISTORY**
Owner present:Gus
Vet:RF 
Owner reports:Presenting for  vaccination and nail trim. History of occasional hotspots and ear infections, but none currently active.
Owner has no other concerns
Recent medication: Nil.

**EXAM**
Hydration normal,mm=pink,CRT=normal
Eyes: NAD
Ears:NAD,mild wax in ext pinnae-owner using cleaner but needs some more
Nasal exam:NAD
Oral exam
Lung auscultation: NAD,no dyspnoea present
Cardiac auscultation:NAD,Heart rate appropriate and regular,no arrhythmia,HR=PR,femoral pulses strong and synchronous
No murmur auscultated
Abdominal palpation:relaxed and comfortable on cranial abdominal palpation,no pain response
Integument:NAD,non pruritic
Ectoparasites: none seen,tick search negative
Musculoskeletal: orthopaedic exam nad
Neurological assessment: nad
Lymphatic system:all peripheral lnn palpate normally with regards to size
Urogenital system:NAD
Rectal palpation:none performed
Anal sac: not examined

Vaccinated with Injectable PI2  5264017  06.01.2027  and oral  BB 524504B  19.11.2026

**ASSESSMENT** :Healthy on examination. good  body condition. 
**PLAN** :
- vaccination administered.
- Nails trimmed.
- Advised light exercise for 24 hours post-vaccination.
- Dispensed Neocort cream. Advised to apply twice daily for 5-7 days for any hotspots and to present for re-examination if no improvement.
- Dispensed ear cleaner. Advised to use every two weeks for routine cleaning.
- Owner to purchase ongoing tick, flea, and heartworm prevention from reception.