Physical Examination Record - Nationwide Pet …

1 In an effort to provide you and your pet with exceptional coverage and affordable premiums, we require that all pets lacking a medical history receive a Physical Examination . During the exam, your veterinarian will make recommendations for care. Policy Number Pet Owner Last Name First Name Pet Name Date of Birth / / Sex.

2 M / FSpayed/Neutered: q Yes q No Breed Color Please have your veterinarian complete the form below. Findings should be documented in detail (such as but not limited to: cataracts, enlargement or discharge from the external genitalia, mam-mary tumors or nodules, skin changes including alopecia, tumors or nodules, cruciate ligament instability, periodontal disease or any ongoing acute or chronic illness). History (including previous and current conditions, treatments, etc.) General Appearance q NRM q ABN (explain)

3 Integumentq NRM q ABN (explain) Musculoskeletalq NRM q ABN (explain)

4 Circulatoryq NRM q ABN (explain) Respiratoryq NRM q ABN (explain)

5 Physical Examination RecordInsurance plans are offered and administered by veterinary Pet insurance company in California and DVM insurance Agency in all other states. Underwritten by veterinary Pet insurance company (CA), Brea, CA, an Best A rated company (2013); National Casualty company (all other states), Madison, WI, an Best A+ rated company (2014).

6 Nationwide , the Nationwide N and Eagle, and Nationwide Is On Your Side are service marks of Nationwide Mutual insurance company . 2015 Nationwide . 15 RET3298PO Box 2344, Brea, CA 92822 1800 E. Imperial Hwy., Suite 145, Brea, CA 92821-6062800-USA-PETS (800-872-7387) FAX 866-332-3994 Inquiries to DVM insurance Agency 714-989-0555 Underwritten by: veterinary Pet insurance company (CA) National Casualty company (Nat l), an A+15 rated companyPhysical Examination Record (cont.) Pet Owner Last Name Digestiveq NRM q ABN (explain) Urogenitalq NRM q ABN (explain)

7 Eyes / Earsq NRM q ABN (explain) Nervous Systemq NRM q ABN (explain)

8 Lymph Nodesq NRM q ABN (explain) Mucous Membranesq NRM q ABN (explain)

9 Are vaccinations up to date? q Yes q NoAdditional testing required: q None q See tests recommended below:_____ _____ Veterinarian Name Signature Date of Examination / / Hospital Name Phone Number

10 Fax Number ( )( ) insurance plans are offered and administered by veterinary Pet insurance company in California and DVM insurance Agency in all other states. Underwritten by veterinary Pet insurance company (CA), Brea, CA, an Best A rated company (2013); National Casualty company (all other states), Madison, WI, an Best A+ rated company (2014). Nationwide , the Nationwide N and Eagle, and Nationwide Is On Your Side are service marks of Nationwide Mutual insurance company . 2015 Nationwide . 15 RET3298 Owner Name Policy Number