Diane’s Discount Pet Supplies Vaccine Clinic Registration

1486 South Hanover Street Pottstown, PA 19465

#610-970-7500
Vaccine Clinic Registration

Date: 6-4-22 Clinic: # 199
Pet Owner Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Telephone: *
DO NOT MAKE SEPARATE APPOINTMENTS FOR MULTIPLE PETS GETTING VACCINES!
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! *

	Pet Name	Dog or Cat	Age	Breed	Color	Gender	Spayed/Neutered? Do not leave blank, put No if not.	under 20#, 20-50#, over 50#	Rabies vaccine. If needed: specify 1 yr or 3 yr
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Reactions to prior vaccines? *

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 *

I understand
I have entered all my pet(s) information correctly and am now ready to select [Services and Quantity] below. Please visit the Lifestyle-based Vaccine Calculator links below to help with your selections. If you have questions about services please email store@ddpets.com or call #610-970-7500 before you submit your form. *

YES
Dog: Lifestyle-based Vaccine Calculator

Cat: Lifestyle-based Vaccine Calculator
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.

Quantity

Canine Combo (6 in 1) DA2PPv+CV $ 21.00
(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

Quantity

Canine Combo with Lepto (7 in 1) DAPPvL2+Cv $ 24.00
(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

Quantity

Leptospirosis 4 $ 17.00
(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

Quantity

Bordetella (Kennel Cough- Oral) $ 17.00
(dog) NOBIVAC® INTRA-TRAC® ORAL This product has been shown to be effective for vaccination of healthy dogs 7 weeks of age or older against Bordetella bronchiseptica. Annual revaccination is recommended.

Quantity

Lyme $ 39.00
(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

Canine Influenza $ 28.00
(dog) Canine Influenza Virus H3N8 -Recommended for healthy dogs 7 weeks of age or older. Booster two to four weeks later - Annual revaccination with one dose is recommended

Quantity

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.

Quantity

Heartworm Test $ 25.00
(dog) Annual testing recommended All dogs greater than 6 months of age should be tested.

Quantity

Heartgard Plus Blue 0-25 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.

Quantity

Heartgard Plus Green 26-50 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.

Quantity

Heartgard Plus Brown 51-100 lbs. $ 58.00
(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.

Quantity

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

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.

Quantity

Feline 1-HCPCh (4 in 1) $ 18.00
(cat) Modified live virus for protection against panleukopenia (cat distemper), calici, rhinotracheitis and chlamydia. For adult cats 6 mos. of age or older. Booster in 3-4 weeks - Annual revaccination recommended. *For kittens 9 weeks of age or older. Booster every 3-4 weeks until kittens are 16-20 weeks old - Annual revaccination recommended.

Quantity

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.

Quantity

Leukemia 2 yr. $ 30.00
(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.

Quantity

Subtotal $ 0.00 Tax $ 0.00 Total $ 0.00
Notes:
(office use only)
Authorization to treat pets - Owner's signature *
(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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