New Patient Registration

New Patient Registration
Client Name:*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Patient Name:*
Pets Name
Species*
Breed*
Patient Breed
Sex*
Patient Birth Date Date:*

MonthDayYear
Color:*
Microchip Info
Microchip Number
Consent to Vaccinations:

I, the undersigned, am aware of the potential risks and benefits of vaccinating my pet. I understand that the majority of adverse reactions are usually minor and will usually resolve without the need for additional veterinary care. However, I also understand that very rarely, life threatening allergic reactions may occur as a result of vaccination. The Pet Doctors of Sherman Oaks make no warranty, either expressed or implied, as to the safety of efficacy of the vaccine being used.

I, the undersigned, understand that I am financially responsible for any and all charges incurred as a result of treating
any adverse reactions that may have been caused by the vaccination.

I, the undersigned, hereby consent to have my dog or cat vaccinated against the following as needed:

Dogs

• Distemper Virus/Adeno Virus Type 2/Parinfluenza/Parvo Virus (DA2PP)
• Canine Influenza
• Leptosporosis
• Bordetella Bronchiseptica (Kennel Cough)
• Rabies Virus
• Rattlesnake Vaccine

Cats

• Feline Herpes Virus/Calici Virus/Panleukopenia (FVRCP)
• Leukemia Virus
• Rabies Virus
E-Signature*

Clear
Print Name*

First NameLast Name
Date*

MonthDayYear
Should be Empty: