Consent Form For Medical Services – Dog ***If your pet needs vaccines and/or diagnostics, this form must be completed in conjunction with either the Boarding Registration form, Dental authorization form, any Surgical release form, or Hospitalization form.*** ***For the protection of your pet, documentation of current proof of vaccines must be provided at time of check-in, unless we are administering them while your pet is here.*** Canine ***Requirements for: drop off appointment, surgery,dental***: Rabies, Distemper/Parvo, Leptospirosis, and a negative Fecal exam within the last 12 months. ***Requirements for boarding***: Rabies, Distemper/Parvo, Leptospirosis, Bordetella, Canine Influenza Bivalent, and a negative Fecal exam within the last 12 months. Feline ***Requirement-***For drop off appointment, surgery, dental, or boarding***: Rabies and Distemper (CVRP) Owner's Full Name* Pet's Name* Best Contact #* This is my...* Cell Work Home What diet (brand/formula) is your pet on at home?* How much do you feed?* How often do you feed?* Lifestyle*Indoor SolitaryIndoor SocialIndoor/OutdoorStrictly OutdoorIs your pet current on Heartworm Prevention (what medication)?* Does your pet have any allergies to food or medications?* Yes No Please provide allergy information**A physical exam is done and charged for prior to vaccinating when required or requested vaccinations are given. There is not a physical exam fee for the kennel cough vaccination when done alone.** ***EXAM,VACCINE AND DIAGNSOTIC TREATMENT REQUESTED (INITIAL ALL THAT APPLY)***Physical Exam (initials) Rabies Vaccine (initials) Distemper/Parvo Vaccine (initials) Leptospirosis (initials) Bordetella (Kennel Cough) (initials) Combo CIV-Canine Influenza (initials) Lyme Vaccine (initials) Rattlesnake Vaccine (initials). Fecal (intestinal parasite test) Heartworm Test (recommended by DVM annually and required to get a refill on prevention) (initials) Pro Heart (initials) Do you need any medication refills? If yes, please list the name of the medication. *All requests subject to doctor approval* IF YOUR PET IS HAVING AN EXAM PLEASE LIST ANY CONCERNS THAT NEED TO BE ADDRESSED WITH THE DR.Digital Signature:* Date:* EmailThis field is for validation purposes and should be left unchanged.