FeLV/FIV ___/___ HW TEST POS / NEG RX ______
Notes
RABIES TAG #
Vaccine / Sick Sign In ( NO SURGERY )
TO RECEIVE SERVICE (OVER 12 WEEKS OF AGE) YOU MUST RECEIVE RABIES OR SHOW PROOF THAT PET IS CURRENT
Last name / First name / Phone / 2nd phoneAddress / Apt / City / State / Zip
Pet’s Information: [_]Cat [_]Dog [_]Other TEMPERMENT ______
Spayed
Name Breed Sex Neutered Color / Description AGE
Y NHow did you acquire this pet & how long have you had this pet? / Past injuries/surgeries/treatments?
Date of Last Heartworm Test Pos Neg On Heartworm prevention? Yes No Last Dose
You may write on the back if needed
Health problems / complaints ?Any changes in - appetite drinking activity * Has pet - sneezed coughed vomited diarrhea
Where does pet live ? outdoor indoor both * Allergies-
Has pet ever had a litter? Yes No If yes, how long ago Any deaths, stillborns?
Current Vaccines / Medications
Reactions to vaccines, medications
What Is Your Pet Having Done Today Please Check Box
Cats Dogs
[_]Kitten Pack 6 - 11 weeks $35Exam, FRCP Vaccine, Worm Treatment / [_] Puppy Pack 6-11 weeks $35
Exam, DA2PPV Vaccine, Worm Treatment
[_]Cat Pack#1(already Spayed/Neutered )$75
Exam, Rabies, FeLV/FIVcombo test , Leukemia & FRCP Vaccine / [_] Dog Pack #1 $60
Exam, Rabies, DA2PPV, Kennel Cough vaccines, Heartworm Test
[_]Cat Pack#2(already Spayed/Neutered) $50
Exam, Rabies FRCP & Leukemia Vaccine / [_] Dog Pack #2 $45
Exam, Rabies, DA2PPV, Kennel Cough Vaccines
[_]Cat Pack #3 (already Spayed/Neutered) $35
Exam, Rabies, FRCP Vaccine / [_] Dog Pack #3 $35
Exam, Rabies, DA2PPV Vaccine
Rabies & Exam Are Free With Surgery
[ [_] Rabies (required by law) $15 / [ [_] Rabies (required by law) $15[_] Exam – (NO Surgery) $10 / [_] Exam – (NO Surgery) $10
[_] Flea Treatment Advantage $15 / [_] Dog DA2PPv vaccine $15
[_] Ear Mite Treatment $10 / [_] Dog Kennel Cough vaccine $15
[_] Cat FeLV/FIV combo test $25 / [_] Heartworm Test $25
[_] Cat FRCP vaccine $15 / [_] Heartworm Prevention
[_] Cat Leukemia vaccine $15 / [_] Worm Treatment
[_]Worm Treatment $10 / [_] Prescription (1800 pet meds) ONE YEAR $10
[_] / [_]
[_] / [_]
*By signing below you agree to the procedures you checked above & refuse the ones you did not check.You state that you are the owner or agent of this animal and have the authority to consent
I understand that risk and potential complications, including death, allergic reactions exist with anesthesia,surgery, heartworm treatment and on rare occasions Vaccines . I accept the stipulation that the veterinariansand staff will not be held liable or
responsible for any complications that may occur including escape. We charge a$25 Returned Check Fee
SIGN______DATE______Paid ______
Please save your pet records, duplicates require a written request