Vaccine Clinic Appointment Reservation

Select your preferred appointment time*

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email Address*

example@example.com

What type of pet are you scheduling?*

CatDog

Pet Name*

Date of Birth (estimate is fine)*

Date

Sex*

Cat Breed*

Dog Breed*

Other Breed Type

Color and Pattern (if applicable)*

What services would you like your cat to receive? Payment can be made at the time of the appointment. Cats must be at least 12 weeks old to receive a rabies vaccine.*

What services would you like your dog to receive? Payment can be made at the time of the appointment. Dogs must be at least 12 weeks old to receive a rabies vaccine.*

Has your pet ever experienced a reaction to vaccines in the past?*

NoYes (include info below)

What type of reaction did your pet have? What treatment (if any) did they receive before or after the vaccinations were administered?*

Vaccine Authorization Form

To the best of my knowledge, my pet is currently healthy, free from any symptoms of illness such as vomiting, diarrhea, coughing, sneezing, lethargy, or loss of appetite. Vaccines are important in reducing or preventing many diseases. I understand they are not always 100% effective, especially if my pet was exposed prior to vaccinations given. I will not hold Feline Fix or its staff or volunteers liable for lack of vaccine efficacy.

Although intended to prevent disease and illness, any vaccine and/ or medication has the potential to cause adverse reactions that cannot always be predicted. It is important that I keep a close eye on my pet after the vaccination, especially for the next 24 hours. I release Feline Fix and its staff, whether paid or volunteer, of liability for such complications and/ or cost associated with such complications. If concerned, I will bring my pet to my primary veterinarian to have these side effects addressed. I understand this may result in additional fees that neither Feline Fix or any of its staff or volunteers will be liable for paying. The volunteer veterinarian and staff does not perform a physical exam prior to administering vaccines. We reserve the right to refuse vaccinations if concerned for the well-being of the animal.

I understand that I must be responsible for my pet(s) while attending the vaccine clinic. This includes keeping them safe and out of harm’s way. Holding all puppies or leaving them in a carrier while waiting. Larger dogs must be on a leash. All cats and kittens must always be in a sturdy appropriate size carrier.

I understand Feline Fix and its staff and volunteers will use all reasonable precautions against injury, escape or death of the animal but that neither Feline Fix nor its employees, volunteers, owners or contractors will be held liable or responsible in any manner. I understand that I assume 100% of the risks with my animal receiving vaccines.

I certify that I am the owner or the authorized agent for the owner of the animal listed on this form, and I have the authority to execute this consent. My signature certifies that I am over 18 years of age.

I agree to the use of any photograph(s) or video(s) of me and/or my pet for educational and promotional purposes of Feline Fix (including but not limited to: webpages, newsletters, brochures, and displays) I further understand that I will not be paid for the use of such photograph(s) or video(s).

Signature*