Which Location?(Required) Boulevard CastletonPet's Name(Required)Date of Birth(Required)Species(Required) Dog Cat Bird Rabbit Ferret OtherColor(s)(Required)Breed(Required)Sex(Required) Male FemaleSpayed/Neutered(Required) Yes NoIf yes, at what age?Date last vaccinated(Required)Date of last Rabies Vaccine?(Required)Any known allergies(Required)Any Previous Medical Conditions or Surgeries?(Required)Current Medications or Supplements given?(Required)Regular/Current Diet(Name of Brand)?(Required)Are you interested in a 6 month heartworm preventative injection?(Required) Yes NoPrevious Veterinarian (name and phone number)(Required)Owner Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) Emergency Contact (name and relation)(Required)Phone(Required)How did you hear about us?(Required)Vaccination Consent Form: The veterinarians at Animal Health Group firmly believe the benefits of vaccination outweigh the risks. However, like any medical procedure, vaccinations carry inherent risks. Although most adverse reactions associated with vaccinations are minor, on rare occasions vaccinations may be associated with serious side effects. Common reactions which normally occur in minutes to hours and subside within 24-48 hours: • Pain or swelling at the injection site • Tired and less active, more quiet than usual • Loss of appetite Very Rare but Severe reactions that require immediate veterinary care: • Rapid, difficult, or noisy breathing (PANTING IN CATS) • Severe trembling • Facial swelling (will be obvious) and/or hives (raised circular swellings on the body) • Sudden onset of vomiting or diarrhea • *UNRESPONSIVE sleepiness from which you cannot awaken your pet If the site of vaccination remains swollen, or is getting larger, one month following vaccination, or is still present three months after vaccination, PLEASE MAKE AN APPOINTMENT WITH US, as this could be the sign of a more serious problem.PAYMENT IS DUE IN FULL AT THE TIME SERVICES ARE RENDERED Master Card, Visa, American Express, Discover, Care Credit and Cash Only. We Do Not accept Checks. No refunds are permitted. All refunds will be in clinic account credit only, no exceptions! Pharmaceuticals and food purchases are final sale. I understand that if I do not pay this account as agreed, the account is subject to costs of collections, attorney fees, and interest (any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum). I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided. By signing this form I agree to the payment terms and have read and accept the vaccination consent above.CAPTCHAΔ
