Green Cove Pet Hospital - Dog Preventive Care Form

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Preventive Care Consent Form for Dogs
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Pet’s Name* This field is required.
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Comprehensive Examination $42.04: This is a thorough physical examination to evaluate your pet’s health. This is required each year before any vaccinations can be administered or prescriptions are filled.
Accept
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Distemper/Parvo Vaccine $20.50 +/- Lepto: Combination vaccine that protects against several serious diseases: Canine Distemper (Respiratory, GI, and Nervous System disease with a high death rate), infectious hepatitis (affects the liver), Parvovirus (highly contagious, GI disease with a 90% death rate in untreated dogs), and Parainfluenza (cellular immunity, respiratory disease).
Accept
Decline
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Leptospirosis Vaccine $20.50 +/- DHPP: Protects against a serious bacterial disease that attacks the kidneys and liver of infected dogs and is zoonotic to humans. It is spread by the urine of wild animals (opossums, etc.), rodents (mice, squirrels, etc.) and contaminated sources of water (rivers, lakes, streams, etc.).
Accept
Decline
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Bordetella (Kennel Cough) Vaccine $22.70: This is recommended for all dogs that are exposed to the respiratory secretions of other dogs (boarding, grooming, dog parks, dog training, etc.). It is required for all dogs staying in the hospital or boarding facility. Combination vaccine that protect against the most common causes of bacterial canine infectious tracheobronchitis, parainfluenza (mucosal immunity), and adenovirus.
Accept
Decline
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Canine Influenza H3N2/H3N8 $35.80: This is recommended for all dogs that are exposed to the respiratory secretions of other dogs (boarding, grooming, dog parks, dog training, etc.). It is required for all dogs staying in the hospital or boarding facility. To protect against two increasingly aggressive respiratory viruses, that have caused death in severe cases.
Accept
Decline
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Rabies Vaccine 1 year $20.44/3 year $43.99: This vaccine protects against the zoonotic disease of Rabies (100% fatal in mammals) and is required by Alabama state law (Code of Ala. §3-7A-2) for any dog over the age of 12 weeks.
Accept
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4DX Heartworm and Tick-Borne Illness Test $37.98: This heartworm check also tests for disease that can be spread by tick bites, including: Ehrlichia Canis, Lyme Disease, and Anaplasma. We recommend this test every year for all dogs and is required to fill heartworm prevention.
Accept
Decline
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Intestinal Parasite Examination $28.69: This test, checking for intestinal parasites is recommended every 6 months for all dogs and is required for all pets that stay here long enough to be walked in our yard.
Accept
Decline
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Heartworm Prevention: Monthly ($11+) or injection every 6 months ($39+); Heartworms are spread by mosquitoes. It is life threatening to have and life threatening to treat. It is much cheaper to prevent heartworms than to treat them. There is a breed of mosquito that prefers to feed indoors. Needed year round.
Accept
Decline
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Flea Prevention: Monthly ($20+) or tablet every 3 months ($56.95); Oral or Topical; fleas can be carried inside on your shoes and can cause serious allergic reactions, illnesses, and tapeworms. Needed year round.
Accept
Decline
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Tick Prevention: Monthly ($20+); Oral or Topical; tick bites transmit diseases such as: Ehrlichia Canis, Lyme Disease, and Anaplasma that can result in a host of illnesses. Needed year round.
Accept
Decline
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Annual Early Detection Screening Bloodwork < 6 years old $76.08: 10 item internal organ analysis, electrolyte analysis, and complete blood cell count.
Accept
Decline
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Annual Early Detection Screening Bloodwork > 6 years old $143.27: 18 item internal organ analysis, electrolyte analysis, thyroid level evaluation, and complete blood cell count.
Accept
Decline
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Annual Early Detection Urinalysis $50.38: 11 part chemical and microscopic analysis of urine to evaluate kidney function, bladder health, and monitor for diabetes, crystals, stones, and urinary tract infections.
Accept
Decline
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I hereby consent to the above marked selections to be performed for or administered to my pet. I have read and/or understand to my satisfaction the information provided to me by Green Cove Pet Hospital on preventive care medicine for my dog. I am aware of the significant benefit and potential for risks of the above selections. No vaccine is 100% protective. An allergic reaction is possible with any new medication/vaccine.

In declining services, I understand that I am not fully protecting my pet from preventable and sometimes life-threatening diseases. The ramification of such a decision on my part may result in costly illnesses in the future and I will not hold Green Cove Pet Hospital liable in any way.
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Owner’s Signature* This field is required.
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Date* This field is required.
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Email* This field is required.
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Owner’s Printed Name* This field is required.
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Witness’s Signature
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Date
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Witness’s Printed Name
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