Time in: ______CSR Initials: ______Norfolk SPCA Feline 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 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 : ______Clinic: ______

Has your pet had any reactions to vaccinations? YES NO If yes, to which ? ______

Is your pet currently on flea/tick prevention? YES NO If yes, what product do you use? ______

Is your pet an indoor , 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 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 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*** /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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