Vaccine Clinic Registration

Rancho Coastal Humane Society

389 Requeza St, Encinitas, CA 92024
New Patient Information Registration and Authorization Form

Community Vet Program Vaccine Clinic
Please fill out this form for EACH animal you intend on bringing.
New Patient Information
Owner*

First NameLast Name
Address*
City/State*
Zip Code*
Phone Number (Home or Cell)*
Alternate Phone Number
Email*
example@example.com
If the animal has a co-owner, please fill out the secondary contact information.
Co-Owner's Name
Phone Number (Home or Cell)
Alternate Phone Number
Email
example@example.com
Animal's Name*
Date of Birth or Approximate Age (Please specify in years/months)*
Species*

Canine/DogFeline/Cat
Sex*

FemaleMale
Is your pet spayed or neutered?*

YesNo
Breed*
Coat Color*
Approximate Weight*
What vaccines will you be needing?*

DAPP (Dogs)FVRCP (Cats)Rabies
Will you be needing a microchip?*

Yes, I will need a microchipNo, the animal is already microchippedNot sure
Microchip Number
Who is your regular veterinarian? Please list name of Doctor and Practice.
Does your pet have any current medical issues or concerns?
Does this animal have any known allergies or drug sensitivities?*

YesNoNot sure
If yes, please explain:
Does this pet have any known behavior problems? (example: separation anxiety, reactive to other animals, fearful)*

YesNo
If yes, please explain:
Please list any other pertinent information concerning your pet's health history:
How did you hear about this program?
Clinic Appointment
Important Check-In Information

Please note: The time you select on this form is your check-in time, not your appointment time.

You must arrive at the check-in table at your selected time. This time reserves your spot in line, and vaccines will be administered on a first-come, first-served basis following check-in. Arriving late may result in a delay or forfeiture of your place in line.

Thank you for your cooperation in helping us run a smooth and efficient clinic!
Appointment*
Event Location & Parking

The clinic will be held at 389 Requeza Street in front of Brock’s Community Pet Food Bank. Parking is limited - please respect neighboring properties and park only in designated RCHS areas or along Requeza Street.
Consent, Waiver and Release
I am the owner of the animal described above, and I have the authority to execute this consent. I am participating voluntarily in the Free Pet Vaccine event sponsored by Petco Love, Veterinary Emergency Group, West Coast Animal Hospital, and Rancho Coastal Humane Society. I understand that all the medications, vaccines, and microchips available at this event have been donated. I hereby consent to the use of these medications, vaccines and microchips in the care and treatment of my pet.

I also understand that all the participants in this event, including Petco Love, Veterinary Emergency Group, West Coast Animal Hospital, Rancho Coastal Humane Society, its staff, volunteers, and or volunteering veterinarians (hereinafter, “Released Parties”) are not legally responsible for treatment and/or results of any services provided today and hereby waive any and all claims of liability against the Released Parties. If a hyper-sensitivity reaction occurs (side effects listed below), a consultation with a veterinarian may be necessary. I further understand that the Released Parties are not financially responsible for charges incurred at a treating veterinary hospital.

Side effects that may arise:

● Redness

● Loss of hair

● Itching with discoloration

● Drooling

● Increased excitability

● Changes in body temperature (lower or higher)

● Tremors

● Vomiting

● Diarrhea

● Lack of coordination

● Seizures

● Lethargy

● Swelling
I have carefully read through this Consent, Waiver and Release Form and fully understand its contents. I understand that this is a full and final release from liability between the Released Parties and me. I sign this form voluntarily and of my own free will.*

I agree to the above statement
Signature*

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Printed Name*

First NameLast Name
Date*

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Date
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Rancho Coastal Humane Society

New Patient Information Registration and Authorization Form

New Patient Information

Clinic Appointment

Consent, Waiver and Release