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Vaccine Booster Authorization Form
GET STARTED
Please complete this form before your visit.
If you have any questions, please contact us!
Please enable JavaScript in your browser to complete this form.
Owner's Name
*
First
Last
Second Contact (Authorized for pet’s healthcare decisions)
First
Last
Has your address changed in the past year?
*
Yes
No
Address
*
Address Line 1
Address Line 2
City
Colorado
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District of Columbia
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Vermont
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State
Zip Code
Please confirm address at your appointment
Primary Phone
*
Email
*
Pet's Name
*
Species
*
Dog
Cat
Sex
*
Male
Male (neutered)
Female
Female (spayed)
Please list any medications/supplements your pet is currently taking
Requested at this appointment
*
DA2PP Combo ($25)
Leptospirosis ($30)
Bordetella Oral ($30)
Rabies ($30)
FVRCP Combo ($25)
Feline Leukemia ($30)
Microchip ($55)
Heartworm Test ($50)
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?
Additional comments or concerns
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
*
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