LUMPKIN COUNTY RABIES VACCINATION CLINIC 04/25/2026

LUMPKIN COUNTY RABIES VACCINATION CLINIC 04/25/2026

Visited Clinic At: Lumpkin Co. 4-H Rabies Clinic
Owner Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Animal Information
DogCat
Animal Name 1:
Color
Breed
Age
MaleFemale
Rabies $10DHPP (Dogs Only) $15FVRCP (Cats Only) $15
Animal Name 2:
DogCat
Color
Breed
Age
MaleFemale
Rabies $10DHPP (Dogs Only) $15FVRCP (Cats Only) $15
Animal Name 3:
DogCat
Color
Breed
Age
MaleFemale
Rabies $10DHPP (Dogs Only) $15FVRCP(Cats Only) $15
Animal Name 4:
DogCat
Color
Breed
Age
MaleFemale
Rabies $10DHPP (Dogs Only) $15FVRCP(Cats Only) $15
Animal Name 5:
DogCat
Color
Breed
Age
MaleFemale
Rabies $10DHPP (Dogs Only) $15FVRCP (Cats Only) $15
Animal Owner’s Acknowledgment (Read and sign below before vaccination)

By signing below, I acknowledge that I am the owner of the animal described above and that I have been informed of the following:
If this request for a rabies vaccination waiver is granted by the appropriate public health authorities, it is only effective until the date indicated below, and that I will need to submit a new request every year, which may or may not be granted.
I should minimize the risk of the animal becoming exposed to rabies by keeping it on my premises or on a leash at all times and minimizing exposure to other animals, especially wild animals.
A waiver from rabies vaccination does not exempt the animal from local or state regulations or laws related to rabies. If this animal is potentially exposed to rabies, or if the animal bites a person, public health authorities may require that the animal be quarantined and observed for signs of rabies, or euthanized immediately and tested for rabies.
Signature*
Date*

MonthDayYear
Vaccine Used:

Producer: Zoetis

Vanguard Rabies 1 year - Lot#842053 Exp 10/15/2026
Vanguard FVRCP 1 year - Lot#862803 Exp 2/23/2027
Vanguard DAPP 1 year - Lot#849302 Exp 11/17/2026

Vaccine Given By Mark Helvie DVM. Georgia License Number: 005827

Dr. David Roberson, DVM. Georgia License Number: 011152

YOU MUST KEEP THIS CERTIFICATE AS PROOF OF VACCINATION.

THE TAG IS NOT SUFFICIENT PROOF.
Clinic Sponsors: Lumpkin County Extension/4-H 706-864-2275 and

VCA Dahlonega Animal Hospital
Only cash or check accepted.
Updates and Guidance
- Remain in your vehicle with your windows up for your safety as well as for the safety of clinic staff until directed.
- Do not attend the clinic if a person — or a pet is — ill.
- Pets must be under control at all times. No mingling with other pets and people.
- Pets must be caged and/or leashed with a fixed length no longer than six feet. Cats should be in a carrier. People must maintain control of their pets. Veterinary staff will not be able to attend to the pet in the vehicle.
Should be Empty:

LUMPKIN COUNTY RABIES VACCINATION CLINIC 04/25/2026

Owner Information

Animal Information

Only cash or check accepted.