January 23rd 2021 Vaccine Clinic

January 23rd 2021 Vaccine Clinic

Once we receive your form, our team will contact you for payment in advance to secure your appointment. Due to limited space and high demand- If we do not have a payment arrangement in advance, your appointment will be automatically cancelled to allow an opening for another pet in need. (You may use this one form for two of your pets, if needed and brining both at same time)
Appointment *
Primary Owner Name: *

First Name Last Name
Co-Owner Name:

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Additional Phone:

Area Code Phone Number
Email *
example@example.com
Have you previously attended our facility? *

Yes No
#1 Pet's Name: *
#1 Pet's Breed: *
#1 Pet's Age or D.O.B. *
#1 Pet's Color: *
#1 Pet's Sex: *

Male-Neutered Female-Spayed Male-Intact Female-Intact
#2 Pet's Name:
#2 Pet's Breed
#2 Pet's Age/D.O.B:
#2 Pet's Color:
#2 Pet's Sex:

Male-Neutered Female-Spayed Male-Intact Female-Intact
Select all that you plan to have done for your pet(s):

Rabies 1yr vaccine $15 Rabies 3yr vaccine $30 DHPP (Distemper) vaccine -Adult Dogs $35 DHPP (Distemper) vaccine- Puppies $25 FVRCP (Distemper) vaccine- Adult Cats $35 FVRCP (Distemper) vaccine- Kittens $25 Bordetella vaccine (dogs only) $18 Lepto vaccine (dogs only) $20 Flu vaccine (dogs only) $35 Heartworm Test (dogs only) $30 FELV (Leukemia) vaccine (cats only) $25 FELV-FIV Test (cats only) $56.06 Deworming $17-$52 (depending on weight) Heartworm Preventive to take home (prices vary) Flea preventive to take home (prices vary) Nail Trim Under 25lbs $10 Nail Trim Over 25lbs $14 Nail Trim Over 100lbs $18 Anal Gland Express $23.73
Once your form is submitted, our office will contact you to review specific preventive pricing/overall total cost and arrange payment to secure your appointment.
I, the undersigned, do hereby certify that I am the owner (or authorized agent of the owner) of the above described animal, and to the best of my knowledge as the owner- my pet(s) is/are healthy and has no recent signs of sickness such as sneezing, coughing, vomiting, diarrhea, nor nasal or ocular discharge. Appetite and activity level is normal. I acknowledge the benefits of vaccinations for my pet(s) and authorize the above selections I have chose, at this time. I am aware that my pet(s) will only be examined for the appropriateness of vaccines selected. This is not a full and complete physical examination by the veterinarian. I understand adverse vaccine reactions, although rare may occur and in that event I as the owner will be responsible for any medical or emergency care necessary.
Signature *

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