Appointment Check-In
Thank you for choosing the Humane Society of St. Lucie County Wellness Center and giving us the opportunity to care for your pet. We will be happy to answer any questions you have about your pet's health and strive to give both you and your pet a positive experience. To ensure the best care possible, please complete this form in its entirety as thoroughly as possible.
Owner Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Primary)
*
-
Area Code
Phone Number
Phone Number (Alternative)
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Have you visited us before?
*
Yes
No
Pet's Details
Name of the Pet
*
Species?
*
Cat
Dog
What is the breed of your pet?
*
What is the color of your pet?
*
Pet's Age
*
Sex?
*
Male
Female
I don't know
Is your pet spayed / neutered?
*
Yes
No
Unknown
Vaccination History (Date and type of last vaccination(s) if known:
*
Has your pet ever had an adverse reaction to a vaccine?
Yes
No
Unknown
Reason for today's visit:
*
Previous health problems?
*
Current medications (if any)?
*
Vaccines and additional services requested today:
Dog
Rabies Vaccine $20
Distemper Vaccine $20
Bordetella Vaccine $20
Heartworm Test $20
Nail Trim $15
Fecal Testing $15
Routine Deworming $10
Cat
Rabies Vaccine $20
Distemper Vaccine $20
FIV/FeLV Test $20
Nail Trim $10
Fecal Testing $15
Routine Deworming $10
Authorization:
I, the undersigned, certify that I am the legal owner or agent of the animal being examined and am of sufficient age and mental capacity to authorize care and treatment of the animal being seen and treated at the Humane Society of St. Lucie County's Wellness Center. I, the undersigned, understand and agree to pay for services rendered at the time of check out. I hereby certify all information provided above is correct and accurate to the best of my knowledge.
Authorization:
Clear
Submit
Should be Empty: