New Patient Registration

Client Name:*

First Name Last Name

Cell Phone Number*

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Patient Name:*

Pets Name

Species*

Breed*

Patient Breed

Sex*

Patient Birth Date Date:*

MonthDay Year

Color:*

Microchip Info

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Consent to Vaccinations:

I, the undersigned, am aware of the potential risks and benefits of vaccinating my pet. I understand that the majority of adverse reactions are usually minor and will usually resolve without the need for additional veterinary care. However, I also understand that very rarely, life threatening allergic reactions may occur as a result of vaccination. The Pet Doctors of Sherman Oaks make no warranty, either expressed or implied, as to the safety of efficacy of the vaccine being used.

I, the undersigned, understand that I am financially responsible for any and all charges incurred as a result of treating
any adverse reactions that may have been caused by the vaccination.

I, the undersigned, hereby consent to have my dog or cat vaccinated against the following as needed:

Dogs

• Distemper Virus/Adeno Virus Type 2/Parinfluenza/Parvo Virus (DA2PP)
• Canine Influenza
• Bordetella Bronchiseptica (Kennel Cough)
• Rabies Virus
• Rattlesnake Vaccine

Cats

• Feline Herpes Virus/Calici Virus/Panleukopenia (FVRCP)
• Leukemia Virus
• Rabies Virus

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