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PET’S INFORMATIONPet’s NameAgeWeightGender ? MALE ? FEMALESpayed/Neutered? ? YES ? NOLength of fur ? SHORT ? MEDIUM ? LONGColorGUARDIAN’S INFORMATIONFirst NameMiddle InitialLast NameAddressCityZip CodePhone (1) ? Cell ? HomePhone (2) ? Cell ? Home Would you like to receive reminders Email: and updates via email? ? Yes ? NoHow long have you been the guardian of this pet?PET’S HEALTH HISTORYYESNOUNKNOWNHave you seen any of these symptoms in the last 2 weeksYESNODo you have any health concerns for your pet?Diarrhea?Is this your cat’s first vaccines?Vomiting?Has your cat ever had a negative reaction to vaccines before?Low energy?Has your cat previously tested positive for FIV or FeLV (feline leukemia)?Decreased appetite?Has your cat bitten anyone in the last 10 days?For office use onlyDoes your cat get carsick?If you have a female cat, is it possible she is pregnant?Does your cat live primarily indoors?161677219022 Cat Vaccine Questionnaire . Account number: ______________________ ? NBH ? NP 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 cats may have an allergic reaction to vaccines; please advise the veterinarian if your pet previously has had an allergic reaction. 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 cat 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 DateEmail records to records@ or fax to 317-638-0993VACCINES_____ Rabies$17 / 19? 1yr? 3yr? Up-to-date_____ 4-in-1$16? Initial? 1st Booster? 2nd Booster? Final/annual_____ Feline Leukemia$21? Initial? Final/annualPACKAGES_____ Mini Package (Rabies, 4-in-1)$32 / 34? Initial? 1st Booster? 2nd Booster? Final/annual_____ Full Package (Rabies, 4-in-1, FeLV)$42 / 44? Initial? 1st Booster? 2nd Booster? Final/annualFIV/FeLV_____ Leukemia/FIV Combo Test$25FIV:? Negative? PositiveFeLV:? Negative? PositivePARASITE PREVENTATIVE_____ Revolution (topical)Single Dose3 month supply$20$60Fleas, ear mites, heartworms, roundworms, hookwormsMust be 8 weeks and older_____ Advantage Multi (topical) Single Dose6 month supply $20$77Fleas, ear mites, heartworms, roundworms, hookwormsMust be 9 weeks and older_____ Advantage II (topical) Single Dose4 month supply$17.25$52.50-58Fleas only (no exam required)Must be 8 weeks and olderPARASITE TREATMENT_____ Strongid-T$12Hookworms, roundworms_____ Drontal $20Hookworms, roundworms, tapeworms_____ Profender$30Hookworms, roundworms, tapeworms_____ Milbemite$25Ear mitesADDITIONAL SERVICES_____ Microchip $22Must be 12 weeks or older_____ Nail Trim$25_____ Cat Carrier$8_____ Office fee$10This will go toward the cost of spay/neuter surgery for your pet.Notes ................
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