Section 1 of 1 in this document

Proof of Pet Vaccination Form

Pet Owner's Name

Full Address

Pet's Date of Birth (Estimated)

Pet's Species

Pet's Sex

Altered?

What services would you like your dog to receive?

What services would you like your cat to receive?

Do you have a second pet you'd like to register?

Pet No. 2: Pet's Species

Pet No. 2: Pet's Sex

Pet No. 2: Altered?

What services would you like your second pet/dog to receive?

What services would you like your second pet/cat to receive?

Do you have a third pet you'd like to register?

Pet No. 3: Pet's Species

Pet No. 3: Pet's Sex

Pet No. 3: Altered?

What services would you like your third pet/dog to receive?

What services would you like your third pet/cat to receive?

Consent to Care: This section is required for your pet to receive service


By signing this form, I give permission for my pet(s) to be examined and vaccinated by the volunteer staff. I acknowledge that such vaccines do not constitute complete health care. I understand it is essential that my pet(s) receive at least a yearly physical examination. I understand that vaccinations may cause rare reactions in pets. I also agree to accept all risks of vaccination and personally accept both legal and financial responsibility for all charges incurred because of all such risks. I also accept that it is my responsibility to seek emergency care as needed and directed. It is also my responsibility to save any documents given to me by this free clinic to document my pet(s) vaccination history as the organization does not guarantee proof of services received after the date received.

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