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5540375-1905000Vaccine 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: Male or FemaleSpayed/Neutered?: Yes or NoBreed or Mix: _____________________________________Colors:______________________________Guardian’s Name: __________________________|___|____________________________________________ FIRST MI LAST Address: _____________________________________________City: _______________ Zip Code:________Phone(1): __________________________________ Phone(2): _______________________________________Email: _____________________________________?History:Does he/she seem healthy to you? Yes or No If not, please explain: ______________________________________________________________________________________________________________How long have you been the guardian of this animal and where did you get this animal? ____________________________________________________________________________________Date of last vaccines: ____________________ No previous vaccines Unknown HistoryHas your dog ever had a negative reaction to vaccines? Yes NoUnknownDate of last heartworm test: _____________________Pos.Neg.No Prev. TestIs your dog currently on heartworm preventative? Yes NoHas your dog bitten anyone in the last 10 days? YesNoDoes your dog get carsick? Yes NoIf you have a female dog, is it possible that she is pregnant?Yes NoHow many other dogs/cats do you have at home? __________________Where do your dogs/cats stay?InsideOutsideBothAnimals 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 rub-bing of the face. If this is a patient’s first vaccine(s), or they have unknown history, they will need a booster in 3-4 weeks ranging $16-21.Each dog 12 weeks 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. ********** Boosters are NOT included in the initial price listed. *****Rabies – 1 year $17____Rabies – 3 year $19____ (Must have proof of previous rabies certificate) 5-in-1* (parvo/distemper) $16____ Initial 1ST booster 2ND booster final/annualBordetella (kennel cough)$16____ Initial final/annualFull Package (Rabies + 5-in-1 + Bordetella) – Save $7 for choosing all three of these vaccines458597032385Vaccination Stickers00Vaccination Stickers1 year rabies + 5-in-1* + Bordetella* $42____3 year rabies + 5-in-1* + Bordetella* $44____Mini Package (Rabies + 5-in-1) – Save $1 for choosing these two vaccines1 year rabies + 5-in-1* $32____ 3 year rabies + 5-in-1* $34____?Deworming & ParasiticidesStrongid-T$12____hookworms and roundwormsDrontal Plus (under 26 lbs)$20____hookworms, roundworms, whipworms, tapewormsDrontal 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 ageOption 1:Heartgard Plus – heartworms, hookworms, roundworms (6wk and older)Individual Dose $16 ____6 month supply by weight$55 ____Option 2:Advantage Multi – fleas, heartworms, hookworms, roundworms, whipworms (7wk and older)Individual Dose $20 ____6 month supply by weight$77-80____Option 3:ProHeart – heartworms, hookworms (6mo and older)6 month injection$37 ____?Flea Control 399605572390Notes:DVM:00Notes:DVM:Option 1: Advantage II – fleas (7wk and older) Individual Dose: $16____ 4 month supply by weight$49-54____Option 2:Nexguard – fleas, ticks (8wk and older)Individual Dose: $23____3 month supply by weight$51-53____Option 3:Simparica – fleas, ticks (6mo or older)Individual Dose: $17____3 month supply by weight$38-41____Option 4:Revolution – fleas, ticks, heartworms for puppies under 5 lbs. (6wk and older)Individual Dose: $20____ 3 month supply by weight $60____?AVID Microchip with Registration (no annual or monthly fees): 3 months and older$22____?Prescription Service (for those who choose to use 1-800-PetMeds, other pharmacies, and online pharmacy services)$10____?Nail Trim If dog’s nails can be trimmed without anesthesia. $25____ ................
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