LOW COST VACCINE CLINIC

Low Cost Vaccine Clinic - Appointment Information

Your current, scheduled appointment will not be confirmed until we receive this form completed in its entirety. Thank you in advance.
DOG'S NAME: *

NAME AGE
*

COLOR BREED
MALE/FEMALE *
IS YOUR DOG SPAY/NEUTERED? *
CLIENT NAME: *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Postal / Zip Code
Spouse/Additional Contact

First/Last Name Phone Number:
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
ARE YOU A NEW CLIENT?
HOW DID YOU HEAR ABOUT US? blanks
PREVIOUS VET:blank

LOW COST VACCINE CLINIC

PAGE 2
VACCINES

BUNDLE:

INCLUDES NOSE TO TAIL EXAM, RABIES VACCINE, DISTEMPER/PARVO (DHLPP), HEARTWORM TEST AND DE-WORMER (STRONGID)

BUNDLE: $65.00

or

RABIES VACCINE ONLY: $9.00
**Residents of Portland will receive a City Tag for an additional fee of $5.00**
BUNDLE OR RABIES VACCINE ONLY? *
ADDITIONAL VACCINES: (PLEASE CHECK ALL THAT APPLY)

BORDETELLA - $20.00 CANINE INFLUENZA - $35.00 RATTLESNAKE - $22.63

PROHEART PRICING

PROHEART 6 - 1 shot provides 6 months of continuous Heartworm protection

PROHEART 12 - 1 shot provides 12 months of continuous Heartworm protection

PROHEART - HEARTWORM PROTECTION RECEIVE $5.00 OFF when purchased with the BUNDLE *

LOW COST CLINIC VACCINE CLINIC

PREVENTATIVES
HEARTGARD - HEARTWORM PREVENTION

HEARTGARD BLUE 0-25 LBS / $10.00 PER DOSE / 6 DOSES FOR $50.00 HEARTGARD GREEN 26-50 LBS / $10.00 PER DOSE / 6 DOSES FOR $54.00 HEARTGARD BROWN 51-100 LBS / $12.00 PER DOSE / 6 DOSES FOR $66.00
I would like to purchase blanks doses from the list above of HEARTGARD {dogsName}.
NEXGARD - FLEA AND TICK PREVENTION

NEXGARD ORANGE 4-10 LBS / $20.00 PER DOSE/ $120.00 PER BOX OF 6 NEXGARD BLUE 10.1-24 LBS/ $20.00 PER DOSE / $120.00 PER BOX OF 6 NEXGARD PURPLE 24.1-60 LBS / $22.00 PER DOSE / $132.00 PER BOX OF 6 NEXGARD BROWN 60.1-121 LBS $22.00 PER DOSE / $132.00 PER BOX OF 6
I would like to purchase blanks doses from the list above of NEXGARD for {dogsName}.
DO you have MORE THAN ONE DOG who has an appointment for the LOW COST VACCINE CLINIC? *

YES NO

LOW COST CLINIC VACCINE CLINIC

Dog #2
DOG'S NAME #2: *

NAME AGE
*

COLOR BREED
MALE/FEMALE *
SPAY/NEUTER? *
BUNDLE OR RABIES VACCINE ONLY? *
ADDITIONAL VACCINES: (PLEASE CHECK ALL THAT APPLY)

BORDETELLA - $20.00 CANINE INFLUENZA - $35.00 RATTLESNAKE - $22.63

LOW COST CLINIC VACCINE CLINIC

PREVENTATIVES
PROHEART - HEARTWORM PROTECTION RECEIVE $5.00 OFF when purchased with the BUNDLE *
HEARTGARD - HEARTWORM PREVENTION

HEARTGARD BLUE 0-25 LBS / $10.00 PER DOSE / 6 DOSES FOR $50.00 HEARTGARD GREEN 26-50 LBS / $10.00 PER DOSE / 6 DOSES FOR $54.00 HEARTGARD BROWN 51-100 LBS / $12.00 PER DOSE / 6 DOSES FOR $66.00
I would like to purchase blanks doses from list above of HEARTGARD for {dogsName113}.
NEXGARD - FLEA AND TICK PREVENTION

NEXGARD ORANGE 4-10 LBS / $20.00 PER DOSE/ $120.00 PER BOX OF 6 NEXGARD BLUE 10.1-24 LBS/ $20.00 PER DOSE / $120.00 PER BOX OF 6 NEXGARD PURPLE 24.1-60 LBS / $22.00 PER DOSE / $132.00 PER BOX OF 6 NEXGARD BROWN 60.1-121 LBS $22.00 PER DOSE / $132.00 PER BOX OF 6
I would like to purchase blanks doses from the list above of NEXGARD for {dogsName113}.
Do you have an appointment for another DOG at the LOW COST VACCINE CLINIC?

YES NO

LOW COST CLINIC VACCINE CLINIC

Dog #3
DOG #3: *

NAME AGE
*

COLOR BREED
MALE/FEMALE *
SPAY/NEUTER? *
BUNDLE OR RABIES VACCINE ONLY? *
ADDITIONAL VACCINES: (PLEASE CHECK ALL THAT APPLY)

BORDETELLA - $20.00 CANINE INFLUENZA - $35.00 RATTLESNAKE - $22.63

LOW COST VACCINE CLINC

PREVENTATIVES
PROHEART - HEARTWORM PROTECTION RECEIVE $5.00 OFF when purchased with the BUNDLE
HEARTGARD - HEARTWORM PREVENTION

HEARTGARD BLUE 0-25 LBS / $10.00 PER DOSE / 6 DOSES FOR $50.00 HEARTGARD GREEN 26-50 LBS / $10.00 PER DOSE / 6 DOSES FOR $54.00 HEARTGARD BROWN 51-100 LBS / $12.00 PER DOSE / 6 DOSES FOR $66.00
I would like to purchase blanks doses from the above list of HEARTGARD for {dog3}.
NEXGARD - FLEA AND TICK PREVENTION

NEXGARD ORANGE 4-10 LBS / $20.00 PER DOSE/ $120.00 PER BOX OF 6 NEXGARD BLUE 10.1-24 LBS/ $20.00 PER DOSE / $120.00 PER BOX OF 6 NEXGARD PURPLE 24.1-60 LBS / $22.00 PER DOSE / $132.00 PER BOX OF 6 NEXGARD BROWN 60.1-121 LBS $22.00 PER DOSE / $132.00 PER BOX OF 6
I would like to purchase blanks doses from the list above of NEXGARD for {dog3}.

LOW COST CLINIC VACCINE CLINIC

SUBMIT
We ask that you complete your forms and submit them no later than three days prior to your appointment date. Your appointment(s) will be confirmed once your completed forms are received by the clinic. We will also reach out to you the week of your appointment with a reminder.

Should you have to cancel your appointment(s) we ask that you do so no later than three (3) days prior to your appointment date.

We look forward to seeing you during the Vaccine Clinic.
Should be Empty:

Low Cost Vaccine Clinic - Appointment Information