Pet Microchip Registration Form

Owner's Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Do you want a microchip for your pet and give permission for a Doctor of Veterinary Medicine to insert it?

Do you have an account with California Veterinary Clinic?

If yes, is it the same name and info or under another name?

If your vet account at California Veterinary Clinic is under another name than the one at the top of the form, please add the name here

Animal's Name

Is your pet a cat or dog?

Animal's Gender

Animal's Breed

Animal's Age

Animal's Coloring

Is the animal fixed (spayed/neutered)?

Does the animal have a current rabies vaccine?

If yes, do you have proof of rabies vaccine?

Would you like a FREE city tag at this event with proof of rabies vaccine? (must send proof of rabies to Mission Monipaw BEFORE appt day)

If no current rabies vaccine, would you like to add a rabies vaccine to your appointment for $37 (due at the vet 11/7 during the event)?

If we host a pet food pantry and supply drive on the same day 11/7 - would you take advantage or need pet food?

Do you have any other needs for your pet? If it is something we can help with, we will contact you, but otherwise this is just to gather information on the needs of the community

Have you paid your $15 prepayment for this appointment to Mission Monipaw?

Note: Appointment is NOT valid without prepayment and must be cancelled at least 2 weeks prior to receive a refund.

We have a dedicated doctor for inserting microchips (pre pay $15) and giving Rabies Vaccines ($37 additional due to the vet that day) at the California Vet Clinic Saturday 11/7/26 8am-12 (noon). Appointments are FIRST COME FIRST SERVE that Saturday and there may be a wait while we get people in as they show up.

An email will be sent to you with confirmation and then reminding you closer to the event.

*Liability and Services Agreement

By signing, submitting this app, and participating in this microchip clinic, I acknowledge that all services are provided voluntarily and at my own risk. I release and hold harmless the hosting rescue organization, the attending veterinarian, their employees, volunteers, and agents from any and all liability, claims, damages, or injuries arising from participation in this event or from the services provided.

I understand that only prepaid microchip services and any rabies vaccinations requested in advance are available at this clinic. No examinations, diagnoses, treatments, prescriptions, or additional veterinary services will be provided. Payment for any pre-requested rabies vaccination is due directly to the veterinarian on the day of the event.