1486 South Hanover Street Pottstown, PA 19465
#610-970-7500
Vaccine Clinic Registration
Date: 2-6-21 Clinic: # 183
Pet Owner Name
*
First Name
Last Name
Type a question
Email
*
example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone:
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Appointment
*
When filling out PET(S) Information below make sure that you: 1. Fill out each section completely! 2. Spayed/Neutered: If your pet is not spayed/neutered, put NOT in that section. 3. Breed: mixed-breed predominant breed/mix. CATS: DSH - shorthaired cat DLH - longhaired cat 4. Rabies: If your pet does not need a rabies vaccine put NO in that section. If your pet needs a rabies vaccine and it is your pet's first vaccine put 1 yr. and 3 yr. for pets that have proof of a prior vaccine. 5. If you are unsure about how to fill out this form or have questions, please call #610-970-7500 prior to submitting this form!
PET(S) Information: List all pets getting vaccines. Do not make separate appointments!
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Pet Name
Dog or Cat
Age
Breed
Color
Gender
Spayed (female) Neutered (male)
under 20#
20-50#
over 50#
Needs
Rabies
1 yr. or 3 yr..
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Reactions to prior vaccines?
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No *We cannot vaccinate pets that have had a previous reaction to a vaccination.
Owner is financially responsible for any vaccination reactions. Who to call in the case of an Emergency: Veterinary Referral Center (610) 647-2950 or Metropolitan Emergency Service (610) 666-0914
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I understand
I have entered all my pet(s) information correctly and am now ready to select [Services and Quantity] below. If you have questions about services please email store@ddpets.com or call #610-970-7500 before you submit your form.
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YES
SERVICES AND QUANTIY
(CHECK BOX)
Select Services & Select Quantity
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Rabies Vaccine: 3 yr. or 1 yr.
$
15.00
(dog & cat) Rabies is a 3 yr. vaccine, unless it is your pet's first vaccine. *You must provide paper proof (tags on collars are not legal proof) of a previous rabies vaccine in order to have a 3 yr. rabies certificate issued. Recommended for healthy dogs/cats 12 weeks of age or older.
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Canine Combo (6 in 1) DA2PPv+CV
$
18.00
(dog) DAPPV+CV =Canine Distemper Virus, Canine Adenovirus type 1 and 2, Canine Parainfluenza Virus, Canine Parvovirus (modified live viruses), Coronavirus (inactivated virus). Recommended for healthy dogs 6 weeks of age or older. Two doses given 2-4 weeks apart -Repeat at 2-4 week intervals until the dog is 12 weeks of age -Annual revaccination with 1 dose is recommended
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Canine Combo with Lepto (7 in 1) DAPPvL2+Cv
$
20.00
(dog) Canine Distemper Virus, Canine Adenovirus type 1 & 2, Canine Parainfluenza Virus, Canine Parvovirus (modified live viruses), Coronavirus (inactivated virus) and Leptospira Canicola-Icterohaemorrhagiae(inactivated bacterin). Recommended for healthy dogs 6 weeks of age or older. Two doses given 2-4 weeks apart -Repeat at 2-4 week intervals until the dog is 12 weeks of age -Annual revaccination with 1 dose is recommended
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Leptospirosis 4
$
16.00
(dog) NOBIVAC LEPTO4 - four-way leptospirosis vaccine - Recommended for healthy dogs 8 weeks of age or older. 2 Doses given 2-4 weeks apart - Annual vaccination recommended
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Bordetella (Kennel Cough- Oral)
$
17.00
(dog) Bordetella bronchiseptica vaccine- Annual vaccination recommended Recommended for healthy dogs 8 weeks of age or older.
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Lyme
$
30.00
(dog) Recommended for healthy dogs 8 weeks of age or older. Two doses given 2 to 4 weeks apart Annual revaccination with 1 dose is recommended.
Quantity
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Canine Influenza
$
23.00
(dog) Canine Influenza Virus H3N8 and H3N2 -Recommended for healthy dogs 7 weeks of age or older. Booster two to four weeks later - Annual revaccination with one dose is recommended
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Heartworm/Lyme/Erlichia/A.Platys (4DX)
$
38.00
(dog) Begin testing dogs at 6 months of age, annual to every 6 months testing is recommended. Even dogs that receive year-round tick control and prevention are at a high-risk for exposure to tick-borne diseases.
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Heartworm Test
$
25.00
(dog & cat) Annual testing recommended All dogs greater than 6 months of age should be tested.
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Heartgard Plus Blue 0-25 lbs.
$
28.00
(dog) 6 month Supply -Heartgard Plus Chewables provide protection against heartworms, and treat and control roundworms and hookworms. RX This item requires an active prescription or proof of a HW test within the last 12 months.
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Heartgard Plus Green 26-50 lbs.
$
38.00
(dog) 6 month Supply -Heartgard Plus Chewables provide protection against heartworms, and treat and control roundworms and hookworms. RX This item requires an active prescription or proof of a HW test within the last 12 months.
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Heartgard Plus Brown 51-100 lbs.
$
48.00
(dog) 6 month Supply - Heartgard Plus Chewables provide protection against heartworms, and treat and control roundworms and hookworms RX This item requires an active prescription or proof of a HW test within the last 12 months.
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Dewormer (Rounds & Hooks)
$
10.00
(dog & cat) Pyrantel Pamoate - Puppies and kittens will often need to be treated every two to three weeks up to 12 weeks of age.
Quantity
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HomeAgain Microchip
$
37.00
(dog & cat) This tiny device provides your pet with permanent identification to give them the best chance of coming home. *Life Time Registration & 1 yr. Membership included.
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Feline 1-HCPCh (4 in 1)
$
18.00
(cat) Modified live virus for protection against panleukopenia (cat distemper), calici, rhinotracheitis and chlamydia. For cats 9 weeks of age or older. Booster in 3-4 weeks - Annual revaccination recommended
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FELV/FIV Combo Test
$
34.00
(cat) Feline Leukemia Virus Antigen-Feline Immunodeficiency Virus Antibody Test Kittens can be tested at 8 wks. for FELV . A negative or positive FIV test should be confirmed when the kitten is 6 months of age.
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Leukemia 2 yr.
$
23.00
(cat) Feline leukemia virus (FeLV) Vaccine is administered to kittens at 9 weeks of age or older. Second dose is administered 3 to 4 weeks later Revaccination every 2 years with a single dose is recommended.
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Subtotal
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0.00
Tax
$
0.00
Total
$
0.00
Authorization to treat pets
*
(signature required at vaccine clinic)
PLEASE KEEP THIS PAPER AFTER THE CLINIC AS PROOF OF VACCINES AND TESTING
*
I understand
*VACCINES NOT VALID WITHOUT VETERINARIAN SIGNATURE
Dr. Amy Pavlock
VETERINARIAN SIGNATURE:
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