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 ______
______
______