Vaccination Options: Please Select All that Apply

+Vaccine Clinic Questionnaire For DOGS

*If your puppy is not fully vaccinated, please keep him/her off the floor!*

Fill out the following information as completely as possible so that we may better serve you and your pet. If you require assistance, please notify a staff member.

Basic Information:

Pet’s Name: ______Age: ______Weight:______

Gender: M or FSpayed/Neutered?: Y or N

Breed or Mix: ______Colors:______

Guardian’s Name: ______

Address: ______City: ______Zip Code: ______

Phone(1): ______Phone(2): ______

Email: ______

History:

  1. Does he/she seem healthy to you? Y or N If not, please explain: ______
    ______
  2. How long have you been the guardian of this animal and where did you get this animal? ______
  3. Date of last vaccines: ______No previous vaccines Unknown History
  4. Has your dog ever had a negative reaction to vaccines? Yes NoUnknown
  5. Date of last heartworm test: ______Pos.Neg.No Prev. Test
  6. Is your dog currently on heartworm preventative? Yes No
  7. Has your dog bitten anyone in the last 10 days? YesNo
  8. Does your dog get carsick? Yes No
  9. If you have a female dog, is it possible that she is pregnant?Yes No
  10. How many other dogs/cats do you have at home? ______
  11. Where do your dogs/cats stay?InsideOutsideBoth

Animals must be in good health to receive vaccinations. Pets with health concerns may not be vaccinated and should be seen by a full-service veterinary clinic. A small percentage of puppies may have an allergic reaction to the 5-in-1 vaccine; please advise the veterinarian if your pet previously has had an allergic reaction, symptoms of which may include facial swelling, swollen ears/muzzle/eyelids, or rubbing of the face.

Each dog 3 months of age and older that has not been spayed/neutered will incur a $10 office fee, which may be credited toward the cost of surgery at the time of spay/neuter at our clinic.

______

Client Signature Date

►Vaccines (*requires booster in 3-4 weeks if it is the first vaccine or if history is unknown)

Rabies – 1 year $17____

Rabies – 3 year $19____ (must have had an unexpired rabies vaccine for the previous year)

5-in-1* (parvo/distemper) $16____ booster needed final/annual

Bordetella (kennel cough)$16____  booster needed final/annual

Full Package (Rabies + 5-in-1 + Bordetella) – Save $8 for choosing all three of these vaccines

1 year rabies + 5-in-1* + Bordetella* $42

3 year rabies + 5-in-1* + Bordetella* $44

Mini Package (Rabies + 5-in-1) – Save $2 for choosing these two vaccines

1 year rabies + 5-in-1* $32

3 year rabies + 5-in-1* $34

►DewormingParasiticides

Strongid-T$12____hookworms and roundworms

Drontal Plus (under 26 lbs)$20____hookworms, roundworms, whipworms, tapeworms

Drontal Plus (over 26 lbs)$26____hookworms, roundworms, whipworms, tapeworms

►Heartworm Test$25____Test Start Time: ______

Recommended for dogs 6 months of age, and annuallyTest Result: NegativePositive

►Heartworm Prevention – must be purchased within 30 days of a negative test for dogs 6+ months of age

Option 1:Heartgard Plus – heartworms, hookworms, roundworms

Individual Dose $16 ____

6 month supply by weight$55 ____

Option 2:Advantage Multi – fleas, heartworms, hookworms, roundworms, whipworms

Individual Dose $20 ____

6 month supply by weight$77-80____

Option 3:Interceptor – heartworms, hookworms, roundworms, whipworms

Individual Dose $14 ____

6 month supply by weight$37-47 ____

►Prescription Service: $10 ____

(for those who choose to use 1-800-PetMeds, other pharmacies, and online pharmacy services)

►AVID Microchip with Registration (no annual or monthly fees): 3 mos and older$22____

►Flea Control

Option 1: Advantage II – fleas

Individual Dose:$16 ____

4 month supply by weight$49-54____

Option 2:Nexguard – fleas, ticks

Individual Dose:$23 ____

3 month supply by weight$51-53____

Option 3:Revolution – fleas, ticks, heartworms

for puppies under 5 lbs.

Individual Dose:$20____

3 month supply by weight $60____

►Nail Trim $15____

If dog’s nails can be trimmed without anesthesia.

$10  Office Fee$35  Medical Exam$10  Prescription Service