PMSPCA Vaccination Clinic application & waiver
** THIS IS ONLY A VACCINATION CLINIC ** Our monthly clinic is open to cats, dogs and ferrets. You MUST choose ONE TIME frame for your appointment (no matter how many pets you are bringing), vaccination(s) needed and pay online prior to attending clinic. Bring the current rabies certificate to determine if your pet receives a 1 or 3 yr vaccine.
Owner Name
*
Phone
*
eMail
*
example@example.com
Physical Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Time attending clinic
*
Clinic date
/
Month
/
Day
Year
Verify time attending clinic
*
Please Select
9a
9:15
9:30
9:45
10a
10:15
10:30
10:45
What is the make and color of your vehicle, so we can identify you for your appointment (ie Silver Suburban)
*
How many pets are you bringing ?
*
Max of 5
Pet 1 Type
*
Dog
Cat
Ferret
Pet 1 Name
*
Pet 1 Breed
*
Pet 1 Gender
*
Please Select
Male
Male, neutered
Female
Female, spayed
Pet 1 Age
*
IE: 2 yrs OR 7 mon
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
Pet 1 Vaccinations requested
*
Rabies (Canine, Feline and Ferret) - $25
Distemper (Canine and Feline) - $25
Lyme (Canine) - $40
Leukemia (Feline) - $30
Kennel cough/Bordatella (Canine) - $25
Microchip - $25
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
*
Are you bringing another pet with you ?
*
Yes
No
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Next
Name 2
Phone 2
Please enter a valid phone number.
Email 2
example@example.com
Address 2
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Clinic date 2
/
Month
/
Day
Year
Time attending clinic 2
Please Select
10 am
10:15
10:30
10:45
11 am
11:15
11:30
11:45
Vehicle 2
Pet 2 Type
Dog
Cat
Ferret
Pet 2 Name
Pet 2 Breed
for cats - short hair, medium hair or long hair
Pet 2 Gender
Please Select
Male
Male, neutered
Female
Female, spayed
Pet 2 Age
IE: 2 yrs OR 7 mon OR DOB
Pet 2 Weight
close approximation, if unknown
Pet 2 Color/markings
Pet 2 How do they behave/react during vet visits ?
Describe any behavior issues
Pet 2 Vaccinations requested
Rabies (Canine, Feline and Ferret) - $25
Distemper (Canine and Feline) - $25
Lyme (Canine) - $40
Leukemia (Feline) - $30
Kennel cough/Bordatella (Canine) - $25
Microchip - $25
Q2a I represent and confirm that I am the legal owner of my pet with full authority to authorize that the requested services be performed
Q2b I understand there are risks associated with the vaccination of animals including but not limited to infections, injury, allergic reaction and death.
Q2c 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
Are you bringing another pet with you ?
Yes
No
Back
Next
Name 3
Phone 3
Please enter a valid phone number.
Email 3
example@example.com
Address 3
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Clinic date 3
/
Month
/
Day
Year
Time attending clinic 3
Please Select
10 am
10:15
10:30
10:45
11 am
11:15
11:30
11:45
Vehicle 3
Pet 3 Type
Dog
Cat
Ferret
Pet 3 Name
Pet 3 Breed
for cats - short hair, medium hair or long hair
Pet 3 Gender
Please Select
Male
Male, neutered
Female
Female, spayed
Pet 3 Age
IE: 2 yrs OR 7 mon OR DOB
Pet 3 Weight
close approximation, if unknown
Pet 3 Color/markings
Pet 3 How do they behave/react during vet visits ?
Describe any behavior issues
Pet 3 Vaccinations requested
Rabies (Canine, Feline and Ferret) - $25
Distemper (Canine and Feline) - $25
Lyme (Canine) - $40
Leukemia (Feline) - $30
Kennel cough/Bordatella (Canine) - $25
Microchip - $25
Q3a I represent and confirm that I am the legal owner of my pet with full authority to authorize that the requested services be performed
Q3b I understand there are risks associated with the vaccination of animals including but not limited to infections, injury, allergic reaction and death.
Q3c 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
Are you bringing another pet with you ?
Yes
No
Back
Next
Name 4
Phone 4
Please enter a valid phone number.
Email 4
example@example.com
Address 4
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Clinic date 4
/
Month
/
Day
Year
Time attending clinic 4
Please Select
10 am
10:15
10:30
10:45
11 am
11:15
11:30
11:45
Vehicle 4
Pet 4 Type
Dog
Cat
Ferret
Pet 4 Name
Pet 4 Breed
for cats - short hair, medium hair or long hair
Pet 4 Gender
Please Select
Male
Male, neutered
Female
Female, spayed
Pet 4 Age
IE: 2 yrs OR 7 mon OR DOB
Pet 4 Weight
close approximation, if unknown
Pet 4 Color/markings
Pet 4 How do they behave/react during vet visits ?
Describe any behavior issues
Pet 4 Vaccinations requested
Rabies (Canine, Feline and Ferret) - $25
Distemper (Canine and Feline) - $25
Lyme (Canine) - $40
Leukemia (Feline) - $30
Kennel cough/Bordatella (Canine) - $25
Microchip - $25
Q4a I represent and confirm that I am the legal owner of my pet with full authority to authorize that the requested services be performed
Q4b I understand there are risks associated with the vaccination of animals including but not limited to infections, injury, allergic reaction and death.
Q4c 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
Are you bringing another pet with you ?
Yes
No
Back
Next
Name 5
Phone 5
Please enter a valid phone number.
Email 5
example@example.com
Address 5
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Clinic date 5
/
Month
/
Day
Year
Time attending clinic 5
Please Select
10 am
10:15
10:30
10:45
11 am
11:15
11:30
11:45
Vehicle 5
Pet 5 Type
Dog
Cat
Ferret
Pet 5 Name
Pet 5 Breed
for cats - short hair, medium hair or long hair
Pet 5 Gender
Please Select
Male
Male, neutered
Female
Female, spayed
Pet 5 Age
IE: 2 yrs OR 7 mon OR DOB
Pet 5 Weight
close approximation, if unknown
Pet 5 Color/markings
Pet 5 How do they behave/react during vet visits ?
Describe any behavior issues
Pet 5 Vaccinations requested
Rabies (Canine, Feline and Ferret) - $25
Distemper (Canine and Feline) - $25
Lyme (Canine) - $40
Leukemia (Feline) - $30
Kennel cough/Bordatella (Canine) - $25
Microchip - $25
Q5a I represent and confirm that I am the legal owner of my pet with full authority to authorize that the requested services be performed
Q5b I understand there are risks associated with the vaccination of animals including but not limited to infections, injury, allergic reaction and death.
Q5c 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
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Pet 1 - total vaccine cost
Pet 2 - total vaccine cost
Pet 3 - total vaccine cost
Pet 4 - total vaccine cost
Pet 5 - total vaccine cost
Total vaccine cost
Payment
*
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USD
Total cost of all vaccines
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