Vaccination Clinic 2025

Owner Name*

First and last name

Phone*

Format: (000) 000-0000.

eMail*

example@example.com

Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code

Time attending clinic*

Clinic date

Verify time attending clinic*

What is the make and color of your vehicle, so we can identify you for your appointment (ie Silver Suburban)*

License plate# of vehicle*

How many pets are you bringing ?*

Max of 5

Pet 1 Information

DogCatFerret

Pet 1 Name*

Pet 1 Breed*

for cats - short hair, medium hair or long hair

Pet 1 Gender*

Pet 1 Date of Birth*

Specific date required; check with your vet if unknown

Pet 1 Weight*

close approximation, if unknown

Pet 1 Color/markings*

Pet 1 How do they behave/react during vet visits ?*

Describe any behavior issues

If your pet is getting a rabies vaccine, you MUST bring the most current
rabies certificate to determine if they will receive a 1 yr or 3 yr vaccine.
Only a veterinarian signed rabies certificate is valid.

PLEASE READ AND INITIAL AGREEMENT

I represent and confirm that I am the legal owner of my pet with full authority to authorize that the requested services be performed.*

I understand there are risks associated with the vaccination of animals including but not limited to infections, injury, allergic reaction and death. *

I hereby release, indemnify and will hold harmless Pope Memorial SPCA of Concord- Merrimack County, its officers, directors, veterinarians, employees, technicians, volunteers and agents ("Releases") from and against any and all claims, costs, damages and losses, including all costs of defense asserted against Releases for whatever reason arising from services provided pursuant to this agreement.*

Owner's Signature*

YesNo

PMSPCA Vaccination Clinic application & waiver

Please note that we are located in Concord, NH