Owner's Name *

First

Last

Second Contact (Authorized for pet’s healthcare decisions)

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Email *

Primary Phone *

May we text you instructions, updates, etc. at this number? *

Yes
No

Secondary Phone

May we text you instructions, updates, etc. at this number?

Yes
No

Pet's Name *

Species *

Dog
Cat

Sex *

Male
Male (neutered)
Female
Female (spayed)

Age/Date of Birth *

Breed *

Color *

Is your cat indoor only or indoor and outdoors? *

Indoor only
Indoor and Outdoors
Indoor and Outdoors (outdoors only with supervision)

Please list any medications/supplements your pet is currently taking

Requested at this appointment *

Click here for more information on vaccines we offer.

Date of your pet’s vaccine appointment *

My pet has been in my care for at least the last two weeks and to the best of my knowledge, my pet is currently healthy, free from any symptoms of illness such as vomiting, diarrhea, coughing, sneezing, lethargy, or loss of appetite. *

Yes
No

If no, please explain what symptoms you are seeing. *

Has your pet had any previous vaccinations? *

Yes
No
Unknown or New Pet

If yes, what clinic may we contact to inquire about records?

Has your pet had any reactions to vaccinations in the past?

Yes
No
Unknown or New Pet

Additional comments or concerns

Please upload the most recent vaccination records

Click or drag files to this area to upload. You can upload up to 5 files.

To the best of my knowledge, my pet is currently healthy, free from any symptoms of illness such as vomiting, diarrhea, coughing, sneezing, lethargy, or loss of appetite. Vaccines are important in reducing or preventing many diseases. I understand they are not always 100% effective, especially if my pet was exposed prior to vaccinations given. I will not hold Animal Works Veterinary Surgery or its staff liable for lack of vaccine efficacy. *

I have read and understand

Although intended to prevent disease and illness, any vaccine and/ or medication has the potential to cause adverse reactions that cannot always be predicted. It is important that I keep a close eye on my pet after the vaccination, especially for the next 24 hours. I release Animal Works Veterinary Surgery and its staff, whether paid or volunteer, of liability for such complications and/ or cost associated with such complications. If concerned, I will bring my pet back to Animal Works or to my primary veterinarian to have these side effects addressed. I understand this may result in additional fees. Animal Works will assist with treatment as much as possible but will not reimburse me for treatments associated with these side effects. Animal Works does not perform exams prior to vaccinations, we reserve the right to refuse vaccinations if concerned for the well-being of the animal. *

I have read and understand

I understand that I must be responsible for my pet(s) while visiting Animal Works Veterinary Surgery, this includes keeping them safe and out of harm’s way. Holding all puppies or leaving them in a carrier while waiting. Larger dogs must be on a leash. All cats and kittens must always be in a sturdy appropriate size carrier. I will pick up any waste my pet has left (disposable bags will be available) *

I have read and understand

I understand Animal Works Veterinary Surgery will use all reasonable precautions against injury, escape or death of the animal but that neither Animal Works nor its employees, owners, or contractors will be held liable or responsible in any manner. I understand that I assume 100% of the risks with my animal receiving vaccines. *

I have read and understand

I certify that I am the owner or the authorized agent for the owner of the animal listed above, and I have the authority to execute this consent. My signature certifies that I am over 18 years of age. I understand this authorization will be valid for multiple vaccination booster visits for my pet up to 3 years from the date of signature; after this time period, I will be required to complete another form. *

I have read and understand

I agree to the use of any photograph(s) or video(s) of me and/or my pet for educational and promotional purposes of Animal Works Veterinary Surgery (including but not limited to: webpages, newsletters, brochures, and displays) I further understand that I will not be paid for the use of such photograph(s) or video(s). *

I agree

Digital Signature *

Vaccine Authorization Form

Please complete this form before your visit.

Got questions?
Feel free to contact us.

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