Low Cost Vaccine Clinic Registration

Vaccine Clinic Registration

Date of Clinic: 5-3-25 Clinic: # 017
We cannot accept feral cats at the vaccine clinic.

All aggressive dogs must be muzzled before arriving at the vaccine clinic.
Pet Owner Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone:*
* DO NOT MAKE SEPARATE APPOINTMENTS FOR MULTIPLE PETS GETTING VACCINES!

* ARRIVE DURING YOUR APPOINTMENT TIME SLOT NOT BEFORE!
Appointment Time Slot*

When filling out PET(S) Information below make sure that you:

1. Fill out each section completely!

2. Spayed/Neutered: If your pet is not spayed/neutered, put NOT in that section.

3. Breed: FOR DOGS: If the dog is a mixed breed put in the predominant breed plus "mix". FOR CATS: Do not leave blank! Typical cat breeds are DSH for shorthaired cat or DLH for longhaired cat or if a purebred, put in that breed.

4. Age: Enter the age the pet will be ON the date of the clinic. This is especially important for young puppies and kittens as age can determine their eligibility for vaccines and certain services.

5. RABIES vaccine: If your pet does not need a rabies vaccine put NO in that section. If your pet needs a rabies vaccine and it is your pet's first time getting the vaccine put 1 year. If your pet has had a rabies vaccine previously in their lifetime, put 3 year.

6. If you are unsure about how to fill out this form or have questions, please call #610-970-7500 prior to submitting this form!

PET(S) Information: List all pets getting vaccines. Do not make separate appointments! *

	Pet Name	Dog or Cat	Age	Breed	Color	Gender	Spayed/Neutered Do not leave blank! Put NO if not.	Weight: under 20#, 20-50# or over 50#	If pet needs Rabies, enter: 1 year OR 3 year
1.
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4.
5.
6.
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10.

Reactions to prior vaccines?*

No *We cannot vaccinate pets that have had a previous reaction to a vaccination.
Owner is financially responsible for any vaccination reactions. Who to call in the case of an Emergency: Veterinary Referral Center (610) 647-2950 or Metropolitan Emergency Service (610) 666-0914*

I understand
I have entered all my pet(s) information correctly and am now ready to select [Services and Quantity] below. Please visit the Lifestyle-based Vaccine Calculator links below to help with your selections. If you have questions about services please email store@ddpets.com or call #610-970-7500 before you submit your form.*

YES
Dog: Vaccine Recommendation

Cat: Vaccine Recommendation
SERVICES AND QUANTIY

(CHECK BOX)
Select Services & Select Quantity
prevnext( X )
Rabies Vaccine: 3 yr. or 1 yr. $22.00
(dog & cat) Rabies is a 3 yr. vaccine, unless it is your pet's first vaccine. *You must provide paper proof (tags on collars are not legal proof) of a previous rabies vaccine in order to have a 3 yr. rabies certificate issued. Recommended for healthy dogs/cats 12 weeks of age or older.

Quantity

Canine Combo (6 in 1) DA2PPv+CV$26.00
(dog) DAPPV+CV =Canine Distemper Virus, Canine Adenovirus type 1 and 2, Canine Parainfluenza Virus, Canine Parvovirus (modified live viruses), Coronavirus (inactivated virus). Recommended for healthy dogs 6 weeks of age or older. Two doses given 2-4 weeks apart -Repeat at 2-4 week intervals until the dog is 12 weeks of age -Annual revaccination with 1 dose is recommended

Quantity

Canine Combo with Lepto (8 in 1) DAPPvL2+Cv$29.00
(dog) Canine Distemper Virus, Canine Adenovirus type 1 & 2, Canine Parainfluenza Virus, Canine Parvovirus (modified live viruses), Coronavirus (inactivated virus) and Leptospira Canicola-Icterohaemorrhagiae(inactivated bacterin). Recommended for healthy dogs 6 weeks of age or older. Two doses given 2-4 weeks apart -Repeat at 2-4 week intervals until the dog is 12 weeks of age -Annual revaccination with 1 dose is recommended

Quantity

Small Canine Combo (5 in 1) EDGE® DAPPv+L4$26.00
(dog) This vaccines .5 ml dose is half the volume of a normal vaccine making it ideal for small breed dogs. For use in healthy dogs 8 weeks of age and older repeated in 2-4 weeks. This vaccine is Thimerosal free and uses VacciPure™ filtration technology making it 99% reaction-free. It protects against Canine Distemper Virus, Canine Adenovirus Type 2, Canine Parainfluenza Virus, Canine Parvovirus (modified live viruses), Leptospira Canicola- Icterohaemorrhagiae, L. Pomona and L. Grippotyphosa.

Quantity

Leptospirosis 4 $21.00
(dog) NOBIVAC LEPTO4 - four-way leptospirosis vaccine - Recommended for healthy dogs 8 weeks of age or older. 2 Doses given 2-4 weeks apart - Annual vaccination recommended

Quantity

Bordetella (Kennel Cough Oral)$21.00
(dog) NOBIVAC® INTRA-TRAC® ORAL This product has been shown to be effective for vaccination of healthy dogs 7 weeks of age or older against Bordetella bronchiseptica. Annual revaccination is recommended.

Quantity

Nobivac® NXT Canine Flu H3N2$29.00
The H3N2 strain of canine influenza continues to be a concern, while the H3N8 strain has been considered “eradicated" in the USA since 2017. The first and only canine influenza vaccine utilizing RNA particle technology is available in a low-volume dose of 0.5 mL, providing a gentler vaccination experience. Healthy dogs aged 8 weeks and older require two doses of the vaccine, which should be administered three to four weeks apart. The necessity for annual boosters is still undetermined.

Quantity

Lyme $42.00
(dog) Recommended for healthy dogs 8 weeks of age or older. Two doses given 2 to 4 weeks apart Annual revaccination with 1 dose is recommended.

Quantity

Heartworm/Lyme/Erlichia/A.Platys (4DX)$40.00
(dog) Begin testing dogs at 6 months of age, annual to every 6 months testing is recommended. Even dogs that receive year-round tick control and prevention are at a high-risk for exposure to tick-borne diseases. This is the test most recommended for our area.

Quantity

Heartworm Test $28.00
(dog) Annual testing recommended All dogs greater than 6 months of age should be tested.

Quantity

Heartgard Plus Blue 0-25 lbs.$52.00
(dog) 6 month Supply -Heartgard Plus Chewables provide protection against heartworms, and treat and control roundworms and hookworms. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Heartgard Plus Green 26-50 lbs.$65.00
(dog) 6 month Supply -Heartgard Plus Chewables provide protection against heartworms, and treat and control roundworms and hookworms. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Heartgard Plus Brown 51-100 lbs.$76.00
(dog) 6 month Supply - Heartgard Plus Chewables provide protection against heartworms, and treat and control roundworms and hookworms RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Iverhart Plus Flavored Chewable for Dogs up to 25 lbs. BLUE (single dose)$6.00
Iverhart Plus Flavored Chewables, when given monthly, can protect your dog from heartworm disease as well as treat and control roundworms and hookworms. Iverhart Plus chewable tablets are tasty and safe, even for puppies as young as 6 weeks of age. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Iverhart Plus Flavored Chewable for Dogs up to 25 lbs. BLUE (6 Month Supply)$28.00
Iverhart Plus Flavored Chewables, when given monthly, can protect your dog from heartworm disease as well as treat and control roundworms and hookworms. Iverhart Plus chewable tablets are tasty and safe, even for puppies as young as 6 weeks of age. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Iverhart Plus Flavored Chewable for Dogs 26 to 50 lbs. GREEN (single dose) $8.00
Iverhart Plus Flavored Chewables, when given monthly, can protect your dog from heartworm disease as well as treat and control roundworms and hookworms. Iverhart Plus chewable tablets are tasty and safe, even for puppies as young as 6 weeks of age. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Iverhart Plus Flavored Chewable for Dogs 26 to 50 lbs. GREEN (6 month supply)$38.00
Iverhart Plus Flavored Chewables, when given monthly, can protect your dog from heartworm disease as well as treat and control roundworms and hookworms. Iverhart Plus chewable tablets are tasty and safe, even for puppies as young as 6 weeks of age. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Iverhart Plus Flavored Chewable for Dogs 50 to 100 lbs. BROWN (single dose)$10.00
Iverhart Plus Flavored Chewables, when given monthly, can protect your dog from heartworm disease as well as treat and control roundworms and hookworms. Iverhart Plus chewable tablets are tasty and safe, even for puppies as young as 6 weeks of age. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Iverhart Plus Flavored Chewable for Dogs 50 to 100 lbs. BROWN (6 Month Supply))$49.00
Iverhart Plus Flavored Chewables, when given monthly, can protect your dog from heartworm disease as well as treat and control roundworms and hookworms. Iverhart Plus chewable tablets are tasty and safe, even for puppies as young as 6 weeks of age. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 5.6-11 lbs. Dogs, 1 Month Supply$29.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 5.6-11 lbs. Dogs, 6 Month Supply $165.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 11.1-22 lbs. Dogs, 1 Month Supply$31.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 11.1-22 lbs. Dogs, 6 Month Supply $176.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 22.1-44 lbs. Dogs, 1 Month Supply$32.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 22.1-44 lbs. Dogs, 6 Month Supply $186.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 44.1-88 lbs. Dogs, 1 Month Supply$34.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Simparica Trio 44.1-88 lbs. Dogs, 6 Month Supply $195.00
Simparica Trio is a once-a-month chewable that protects your dog against heartworm disease, ticks & fleas, roundworms & hookworms. FDA-approved to block infections that may cause Lyme disease by killing deer ticks. RX This item requires an active prescription or proof of a HW test within the last 12 months.

Quantity

Selarid Topical for Puppies & Kittens, 0-5 lbs. (single dose) $11.00
Selarid is recommended for use in dogs six weeks of age or older and cats eight weeks of age and older for the following parasites and indications: Dogs: Kills adult fleas and prevents flea eggs from hatching for one month and is indicated for the prevention of heartworm disease, treatment and control of ear mite infestations, treatment and control of sarcoptic mange and for the control of tick infestations. Cats: Kills adult fleas and prevents flea eggs from hatching for one month and is indicated for the prevention of heartworm disease, treatment and control of ear mite infestations and roundworm and hookworm infections in cats.

Quantity

Selarid Topical Solution for Cats, 5.1-15 lbs. (single dose)$12.00
Selarid is recommended for use in cats eight weeks of age and older. Selarid kills adult fleas and prevents flea eggs from hatching for one month, prevention of heartworm disease, treatment and control of ear mite infestations and for the treatment and control of roundworm and intestinal hookworm infections.

Quantity

Dewormer (Rounds & Hooks)$10.00
(dog & cat) Pyrantel Pamoate - Puppies and kittens will often need to be treated every two to three weeks up to 12 weeks of age.

Quantity

HomeAgain Microchip$37.00
(dog & cat) This tiny device provides your pet with permanent identification to give them the best chance of coming home. *Life Time Registration & 1 yr. Membership included.

Quantity

Dog Nail Trim$20.00
Monthly nail trimming is healthy for your dog and your floors. Overgrown nails can twist toes to one side, grow into the paw pad, causing pain when your dog walks and the potential for infection. They can get caught in carpet, blankets and even their collar. Chronic long nails can cause numerous joint problems and arthritis in the feet.

Quantity

Feline 1-HCPCh (4 in 1) $19.00
(cat) Modified live virus for protection against panleukopenia (cat distemper), calici, rhinotracheitis and chlamydia. For adult cats 6 mos. of age or older. Booster in 3-4 weeks - Annual revaccination recommended. *For kittens 9 weeks of age or older. Booster every 3-4 weeks until kittens are 16-20 weeks old - Annual revaccination recommended.

Quantity

Leukemia 2 yr.$38.00
(cat) Feline leukemia virus (FeLV) Vaccine is administered to kittens at 9 weeks of age or older. Second dose is administered 3 to 4 weeks later Revaccination every 2 years with a single dose is recommended.

Quantity

FELV/FIV Combo Test$42.00
(cat) Feline Leukemia Virus Antigen-Feline Immunodeficiency Virus Antibody Test Kittens can be tested at 8 wks. for FELV . A negative or positive FIV test should be confirmed when the kitten is 6 months of age.

Quantity

Subtotal $0.00Tax $0.00Total $0.00
Notes:
(office use only)
Test Results:
Heartworm:
Lyme:
Erlichia:
A.Platys:

FeLV:
FIV:(office use only)
Authorization to treat pets - Owner's signature*
(signature required at vaccine clinic)
PLEASE KEEP THIS PAPER AFTER THE CLINIC AS PROOF OF VACCINES AND TESTING. IF YOU LOSE YOUR PROOF OF VACCINATIONS THERE IS A $5.00 REPRINT FEE*

I understand
*VACCINES NOT VALID WITHOUT VETERINARIAN SIGNATURE
Dr. Amy Pavlock VMD
VETERINARIAN SIGNATURE:
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