Date:_______________ DIXIE DAY SPAY – Michael Guedron D.V.M.
182 Airport Road NW Cleveland, TN 37312
Last Name _________________________First _________________________ Phone__________________________
Address ____________________________________________________ City ____________________ State _____
Pet name __________________________________________ Zip Code ______________________
Circle: Dog Cat Male Female Approx. Age __________ Weight _____________
Breed: ___________________________________ Color:_____________________________________
Has your pet received vaccinations before? ____ If any reaction to vaccinations, please explain: ___________________
Any past or current medical conditions: ________________________________________________________________
Consent for vaccinations:
_____I here by consent and authorize the administering of vaccinations.
_____ Dixie Day Spay has agreed to vaccinate my animal. Although Dixie Day Spay will exercise responsible care and attention to my animal, Dixie Day Spay ◘
cannot be held responsible for any and all liability. With any vaccination, there is always the risk of adverse reactions, although very rare. These could result in illness, or in extreme cases, death.
____ Dixie Day Spay recommends that you wait for a period of 15 minutes after vaccinations before leaving the clinic in order to observe the animal for any signs of adverse reaction (s).
____ Therefore I will in no way hold Dixie Day Spay or any persons associated with Dixie Day Spay responsible for the outcome of any vaccination.
Signature _______________________________________________________________ Date ___________________________
IS THIS YOUR PET’S FIRST RABIES VACCINE? ________ If so, your animal will receive a 1 year vaccine.
DOGS ________________ CATS
____ RABIES vaccine (3 YEAR) $10 _____ RABIES vaccine $10
____ DHPP (Distemper, hepatitis, parvo, parainfluenza) $10 _____ FVRCP (upper respiratory infections) $10
____ BORDATELLA (kennel cough) $10 _____ FELV (Feline Leukemia) $10
____ HEARTWORM TEST $15 ____ Nail Trim $5 _____ Feline Leukemia Test $20
____ Deworm (Strongid - round worms) Adults $5 Kittens & Puppies $3
MICROCHIP with lifetime registration $20 _______
Iverhart Plus for DOGS 6 month supply (Heartworm, Hookworm, Roundworm preventative)
Six months: Up to –25 lbs $27 25.1 – 50 lbs $32 50.1 – 100 lbs $38
Each: $5 $6 $7
Advantage for fleas: Under 10 lbs - $6 10-20 lbs - $8 21-55 lbs - $11 over 55lbs - $13
Frontline for fleas & ticks: Cats - $7 Dogs: 8-22 lbs - $9 23-44 lbs - $10 45-88 lbs - $12 Over 88 lbs - $14