Low Cost Vaccine Clinic Registration

1486 South Hanover Street Pottstown, PA 19465

#610-970-7500
Vaccine Clinic Registration

Date of Clinic: 12-02-23 Clinic: # 217
Pet Owner Name*

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

Street Address

Street Address Line 2

CityState / Province

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

* ARRIVE DURING YOUR APPOINTMENT TIME SLOT NOT BEFORE!
Appointment Time Slot*
IF YOU NEED TO CANCEL OR CHANGE YOUR APPOINTMENT email: store@ddpets.com

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: DOGS: If the dog is mixed-breed put in the predominant breed + mix. CATS: DSH=shorthaired cat or DLH=longhaired cat

4. RABIES vaccine: 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. or put 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#	Needs Rabies, If yes put in: 1 year or 3 year.
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10.

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. $22.00
(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$26.00
(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$29.00
(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

Small Canine Combo (5 in 1) EDGE® DAPPv+L4$26.00
(dog) This vaccines .5 ml dose is half the volume of a normal vaccine making it ideal for small breed dogs. For use in healthy dogs 8 weeks of age and older repeated in 2-4 weeks. This vaccine is Thimerosal free and uses VacciPure™ filtration technology making it 99% reaction-free. It protects against Canine Distemper Virus, Canine Adenovirus Type 2, Canine Parainfluenza Virus, Canine Parvovirus (modified live viruses), Leptospira Canicola- Icterohaemorrhagiae, L. Pomona and L. Grippotyphosa.

Quantity

Leptospirosis 4 $21.00
(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)$21.00
(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

Canine Influenza (H3N2/H3N8) $47.00
For vaccination of healthy dogs 8 weeks of age or older. Healthy dogs should receive 2 doses administered 3 weeks apart. The need for annual booster vaccinations has not been established for this product; consultation with a veterinarian is recommended. Socially active puppies and adult dogs at highest risk for Canine Influenza Virus are those that are in contact with other dogs or areas where other dogs have been.

Quantity

Lyme $42.00
(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

Heartworm/Lyme/Erlichia/A.Platys (4DX)$40.00
(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$28.00
(dog) Annual testing recommended All dogs greater than 6 months of age should be tested.

Quantity

Heartgard Plus Blue 0-25 lbs.$45.00
(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.$55.00
(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.$65.00
(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

VetriShield Plus Flavored Chewable for Dogs up to 25 lbs. BLUE (single dose)$5.00
VetriShield Plus Flavored Chewables, when given monthly, can protect your dog from heartworm disease as well as treat and control roundworms and hookworms. VetriShield Plus chewable tablets are tasty and safe, even for puppies as young as 6 weeks of age. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

VetriShield Plus Flavored Chewable for Dogs 26 to 50 lbs. GREEN (single dose) $7.00
VetriShield Plus Flavored Chewables, when given monthly, can protect your dog from heartworm disease as well as treat and control roundworms and hookworms. VetriShield Plus chewable tablets are tasty and safe, even for puppies as young as 6 weeks of age. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

VetriShield Plus Flavored Chewable for Dogs 51 to 100 lbs. BROWN (single dose) $9.00
VetriShield Plus Flavored Chewables, when given monthly, can protect your dog from heartworm disease as well as treat and control roundworms and hookworms. VetriShield Plus chewable tablets are tasty and safe, even for puppies as young as 6 weeks of age. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 5.6-11 lbs. Dogs, 1 Month Supply$25.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 5.6-11 lbs. Dogs, 6 Month Supply $150.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 11.1-22 lbs. Dogs, 1 Month Supply$25.50
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 11.1-22 lbs. Dogs, 6 Month Supply $153.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 22.1-44 lbs. Dogs, 1 Month Supply$27.50
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 22.1-44 lbs. Dogs, 6 Month Supply $165.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 44.1-88 lbs. Dogs, 1 Month Supply$28.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 44.1-88 lbs. Dogs, 6 Month Supply $168.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. 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

Dog Nail Trim$20.00
Monthly nail trimming is healthy for your dog and your floors. Overgrown nails can twist toes to one side, grow into the paw pad, causing pain when your dog walks and the potential for infection. They can get caught in carpet, blankets and even their collar. Chronic long nails can cause numerous joint problems and arthritis in the feet.

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) $19.00
(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

Leukemia 2 yr.$38.00
(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

FELV/FIV Combo Test$42.00
(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

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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. IF YOU LOSE YOUR PROOF OF VACCINATIONS THERE IS A $5.00 REPRINT FEE*

I understand
*VACCINES NOT VALID WITHOUT VETERINARIAN SIGNATURE
Dr. Amy Pavlock
VETERINARIAN SIGNATURE:
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