Vaccine Consent Form

Name*

First NameLast Name

Pet's Name*

First NameLast Name

Email

example@example.com

Immunizing your pet is an important procedure as it's one of the most cost-effective ways of maintaining a pet's health, longevity and quality of life. In most cases it will provide protection against an illness that may be life threatening.

Important facts about vaccines:

· We follow the AVMA (American Veterinary Medical Association), AAHA (American Animal Hospital Association), and AAFP (American Association of Feline Practitioners) guidelines for our vaccine protocols for our hospital and boarding facilities.

· Vaccinations given at the appropriate age and at the appropriate intervals will greatly benefit your pet and protect him/her against some life threatening diseases.

· Although most pets do not react adversely to a vaccination, some have had allergic or other systemic reactions after receiving a vaccine. Occasionally the allergic reaction can be so profound that it may be life threatening, however this is very rare.

· Vaccine decisions should only come after your pet's age and the risk of exposure to disease are considered by you and your veterinarian. Our staff does offer the basic vaccine guidelines, however, if you have further questions about appropriate vaccines for your pet, we recommend your dog receive vaccines as an appointment with a veterinarian with a discussion.

· Considerations for vaccines: The AVMA/AAHA lists Rabies and Distemper-Parvo vaccines as CORE vaccines for dogs, meaning all dogs should be protected against these diseases. NON-CORE vaccines include leptospirosis, influenza, and bordetella, which are recommended for dogs who spend significant time outdoors, in parks, campgrounds, or visit boarding or grooming facilities.

Has your pet been sick within the last 72 hours?*

Do you have any medical concerns for your pet that you'd like to discuss with a veterinarian prior to vaccination? *

What medical concerns do you need to discuss with veterinarian?

Has your pet ever had an allergic reaction to a vaccination or injectable medication?*

Has your pet received any vaccinations within the last 14 days?*

Is your pet pregnant? *

Vaccinations your pet will be receiving today. * - indicates to stay at facility*

	1 year	3 year	3 week Booster	6 months
Rabies*
DH(L)PP
DHPP*
Leptospirosis
Influenza Bivalent*
Lyme
Bordetella*

Please check one of the boxes below.

I request examination of my pet prior to vaccination.I decline examination of my pet prior to vaccination.

**Consent for treatment of a vaccine reaction/premedication when indicated for a known vaccine reactor:

I consent to a Benadryl injection in the event that my pet is having a vaccine reaction or is known to have reacted adversely to vaccines in the past. I accept there will be additional cost for treatment if my pet is having a reaction to a vaccine.

I consent

Vaccine Reaction Signs:

Vaccine reactions are unpredictable. Signs to monitor for are swelling of the face/lips, hives along the body, vomiting, diarrhea, soreness/increased pain or swelling at the injection site, listlessness, fever - typically these signs will occur within the first 24 hours of vaccine administration.

*If you see these signs, please give a dose of Benadryl and call us to let us know your pet had a reaction. Benadryl dose is 1 mg per 1 lb (i.e. a 25 lb dog would receive 25 mg). Make sure the only active ingredient is ‘diphenhydramine’ as some cold/flu formulations can be toxic to dogs. You can give Benadryl every 8-12 hours as needed.

**If we are not open and your pet is having a severe reaction, please take them to the Cabarrus Emergency Clinic for further care.

Cabarrus Emergency Clinic

1317 S. Cannon Blvd.

Kannapolis, NC 28083

704-932-1182

Informed Consent: Please read and sign.

By my signature below, I consent to the administration of the vaccine(s) checked on the form above to my pet by a veterinarian or a supervised veterinary technician or supervised veterinary assistant as per NC Veterinary Medical Board guidance. I certify I have read the above information and I am aware of the risks associated with failure to vaccinate my pet as well as the potential side effects associated with receiving the vaccination(s). Because vaccination reactions are not predictable, I agree that the veterinarians at Lazy 5 Veterinary Hospital shall not be held liable for any reactions related to the administration of vaccinations administered to my pet. I understand that I am obligated to pay for all products/services received. I am responsible for bringing my pet to follow up with my veterinarian at my expense if my pet experiences any side effects. I further agree to hold my veterinarian harmless when in the event the effort to reduce the frequency and minimize known complications of vaccination inadvertently increases my pet's risk when exposed to a disease and I shall be responsible for fees related to treating any of the diseases for which a vaccine was not administered.

Signature

Today's Date*

Date