Vaccine Consent and Risk Assessment

Vaccine Consent and Risk Assessment
Client Name*
Pet's Name*
Doctor is authorized to proceed with services based on his/her recommendation.
OR check those that apply:
CANINE:
Exam / Vaccinations

Physical Exam ($76.00)Rabies Vaccine ($43.50)DHPP Vaccine ($34.50)Bordetella Vaccine ($39.00)Influenza Vaccine ($46.50)Leptospirosis Vaccine ($39.00)Lyme Vaccine ($56.50)
Lab Work:

Adult Canine Wellness Basic Panel ($187.20) includes CBC, Chem, UA, Accuplex, Fecal, SDMASenior Canine Wellness Comprehensive Panel ($287.60) includes CBC, Superchem, UA, T4, Accuplex, Fecal, SDMAAccuplex (Heartworm/Tick Panel) ($69.50)Fecal Exam ($61.80)
Help us learn more about your dog by checking the following that apply:

My dog lives mainly/strictly indoorMy dog lives indoor/outdoorMy dog lives mainly/strictly outdoorMy dog goes for controlled walks with me in the neighborhoodI take my dog on hiking, hunting, or camping tripsMy dog goes to the park and plays with other dogsMy dog visits or lives on a farm or another rural facilityMy dog goes to a boarding facility and/or the groomer regularly
FELINE:
Exam / Vaccinations

Physical Exam ($76.00)Rabies Vaccine ($39.50)FVRCP Vaccine ($36.00)Feline Leukemia Vaccine ($49.50)
Lab Work:

Adult Feline Wellness Basic Panel ($228.50) includes CBC, Chem, UA, SDMA, Retroviral FeLV/FIVSenior Feline Wellness Comprehensive Panel ($254.00) includes CBC, Superchem, UA, T4, SDMA, FeLV/FIV
Help us learn more about your cat by checking the following that apply:

My cat lives mainly/strictly indoorMy cat lives indoor/outdoorMy cat lives mainly/strictly outdoorMy cat has contact with other cats that have access to outdoorsI feed the stray cats in my neighborhoodMy cat loves to huntMy cat fights other cats/dogs/wildlifeMy cat has tested positive for feline leukemiaMy cat has tested positive for feline AIDs (FIV)
CANINE AND FELINE:
My pet has been diagnosed with the following chronic disease(s):
My pet is currently taking the following medications:
Current diet (ex. Pedigree, Purina Pro-Plan, Friskies, etc.)
Current heartworm and flea/tick preventatives (ex. Heartgard, Nexgard, Bravecto), etc.
I elect to proceed with the selected vaccines(s) and services, based on my pet's current risk factors. I agree to hold my pet's veterinarian harmless in the event such compliance with traditional protocols and labeling laws inadvertently causes a medical complication associated with the use of the selected vaccine. I understand that a physical exam may be required before vaccinations are administered. I understand that a physical exam is required for the well-being of my pet and to maintain a current doctor-patient relationship.
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