Norfolk SPCA Feline Vaccination Clinic Client/Patient Information Form

Time in: ______________ CSR Initials: ___________ Norfolk SPCA Feline Vaccination Clinic Client/Patient Information Form Client Name: ___________________________________________ Date: ___________________________________________ Address: ______________________________________________ City: ______________________State: _________ Zip: ______ Contact Number: ___________________________________________E-mail Address: ___________________________________ Please provide your email for updates on your animal and to be added to our email list. Patient Name: ___________________________________________ Sex: Male Female Age: ____________________ Breed: _________________________________________________ Color: _________________ Weight: __________________ Spayed or Neutered: YES NO UNSURE If unspayed, is your female pregnant? YES NO UNSURE Physical Status: Is your pet in good health today? YES NO If No, please explain: _______________________________________________________________________________ Does your pet have any history of health problems? YES NO If yes, please explain: _______________________________________________________________________________ Has your pet been vaccinated before? YES NO Date of last vaccinations: __________________________________ Clinic: ___________________________________________ Has your pet had any reactions to vaccinations? YES NO If yes, to which vaccine? ____________________________________________________________________________ Is your pet currently on flea/tick prevention? YES NO If yes, what product do you use? _____________________________________________________________________ Is your pet an indoor cat, outdoor cat or both? IN OUT BOTH Has your pet bitten anyone in the past 10 days? YES NO If yes, does your pet have a current Rabies vaccination? YES NO Has your cat ever had seizures? YES NO If yes, is your pet currently on anti-seizure medications? YES NO *The walk in vaccine clinic is for healthy pets in need of preventative care. If your pet is ill or injured, or the clinic staff is unable to safely handle your pet, you may be directed to a regular veterinarian for treatment. **An allergic reaction following the administration of a vaccine is possible. Please contact a veterinarian if you see any of the following: vomiting, diarrhea, lethargy, swelling, fever, pain or difficulty breathing. Payment is due in full at time of services. The Norfolk SPCA accepts cash, Visa, Mastercard, Discover and American Express (with valid I.D.) NO CHECKS. Signature: _______________________________________________________Date: ______________________________________ Name: __________________________________ Weight: _______________ Please Check Services Wanted Decline ***Clinic staff use only*** Vaccines/Tests Pre-vaccination Exam (Required) $10 required FVRCP/Distemper: Date of Last Vaccine: _________ _________ $17 ______ ______ 8-11 wks 12-15 wks _________ _________ 1st adult Yearly $17 ______ ______ Feline Leukemia: 1st Yearly (or 2nd vaccine booster) $15 ______ ______ Rabies: 1 year 3 year Too young (less than 12 wks. old) $15 ______ ______ Previous RV Date: ________ FeLV/FIV/HW Test Negative Positive: FeLV $27 ______ ______ Negative FIV Negative HW Flea/Heartworm Prevention: (Topical) Flea (Topical) Revolution Single Dose single______ Size (lbs.) Price < 5 $14.00 5-15 $16.00 15-22 $16.00 Other Deworming: Strongid (6m and under) Amt. given: ______ $12 ______ Droncit Qty: ______ (price varies by dosage) $ -- ______ Drontal Qty: ______ (price varies by dosage) $ -- ______ Nail Trim: (depending on difficulty) $12 ______ $16 ______ Microchip: Includes registration $30 ______ OK TO VACCINATE: YES NO ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________.

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