Vaccine Clinic Questionnaire for Dogs and Puppies

By Frances Wells,2014-04-21 22:18
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Vaccine Clinic Questionnaire for Dogs and Puppies

    Dog’s Name_____________________________ Date__________

    *Dogs must be in good health to receive vaccinations; those dogs with health concerns may not be vaccinated and should be seen by a full service veterinary clinic. There are a small percentage of dogs that will have an allergic reaction to the 5in1 vaccination. Please advise the veterinarian if your dog has had a previous allergic reaction to vaccines. Symptoms of a reaction may include facial swelling, swollen ears, muzzle or eyelids and/or rubbing of the face.


Dogs over 1 year of age

    Rabies 1 year $16.00_________ (first Rabies, expired Rabies, or unknown history; booster in 1 year)

     Rabies 3 year $16.00_________ (last Rabies has not yet expired; booster in 3 years)

    5in1 (Distemper,Parvo) $14.00_________ (booster in 3-4 weeks if this is first vaccine or history is unknown)

    Bordetella (kennel cough) $14.00_________ (recommended for dogs who are boarded, visit grooming facilities,

     dog parks, doggy daycare, etc; booster in 1 year)

    Mini Package (3 year Rabies available only if last Rabies has not yet expired)

     1 year Rabies + 5in1 $27.00_______ 3 year Rabies + 5in1 $27.00_______

    Full Package (3 year Rabies available only if last Rabies has not yet expired)

     1 year Rabies, 5in1, Bordetella $37.00_______ 3 year Rabies, 5in1, Bordetella $37.00_______

    Heartworm Test dogs over 6 months of age, and annually $22.00__________

     Test Results: Negative / Positive

    Dewormer (oral)

    Hookworm, Roundworm, Whipworm and Tapeworm

     Drontal Plus for dogs under 26lbs $15.00__________ Drontal Plus for dogs over 26lbs $22.00__________ Hookworm and Roundworm only

     Strongid-T __________cc $12.00__________

Heartworm Preventative Test required if over 6 months of age; must be purchased within 30 days of a negative test

    Interceptor (Heartworm, Hooks, Rounds, Whips) (oral) *WHILE SUPPLIES LAST

    Interceptor for dogs Individual Dose $ 8.00 __________ Heartgard Plus (Heartworm, Hooks, Rounds) (oral)

    Interceptor for dogs 2-10lbs (6 months) $31.00__________ Heartgard Plus for dogs Individual dose $ 8.00________ Interceptor for dogs 11-25lbs (6 months) $33.00__________ Heartgard Plus for dogs 0-25lbs (6 months) $30.00________ Interceptor for dogs 26-50lbs (6 months) $34.00__________ Heartgard Plus for dogs 25-50lbs (6 months) $35.00________ Interceptor for dogs 51-100lbs (6 months) $37.00__________ Heartgard Plus for dogs 51-100lbs(6 months) $39.00________

    Advantage Multi for Dogs (Heartworm, Fleas, Hooks, Rounds, Whips) (topical)

    Advantage Multi for dogs Individual Dose $15.00________

    Advantage Multi for dogs 3-9lbs (6 months) $69.00________

    Advantage Multi for dogs 9.1-20lbs (6 months) $69.00________

    Advantage Multi for dogs 20.1-55lbs (6 months) $73.00________ AVID Microchip with Registration $20.00________

    Advantage Multi for dogs 55.1-88lbs (6 months) $74.00________

    Advantage Multi for dogs88.1-110lbs (6 months) $77.00________

Flea Control (topical) Flea and Tick Control (topical)

    Advantage for dogs Individual Dose $12.00________ Frontline Plus Individual Dose $14.00________ Advantage for dogs Up to 10lbs (4 months) $42.00________ Frontline Plus for dogs Up to 22lbs (3 months) $37.00________

    Advantage for dogs 11-20lbs (4 months) $42.00________ Frontline Plus for dogs 23-44lbs (3 months) $38.00________ Advantage for dogs 21-55lbs (4 months) $43.00________ Frontline Plus for dogs 45-88lbs (3 months) $39.00________ Advantage for dogs Over 55lbs (4 months) $44.00________ Frontline Plus for dogs 89-132lbs (3 months) $40.00________

*Each cat/dog 3 months of age (and older) & not spayed/neutered will be charged a

    $10 office visit fee, refundable at time of spay/neuter.

     Vaccine Clinic Questionnaire for Dogs Your Client #_________

    *You will be called by your Client #; please return this completed form to the front desk

    Dog’s Name______________________________ Age__________ Weight__________ Male_______ Female_______

    Spayed/Neutered: Y N Name of Breed or Mix_________________________ Colors____________________________

    Guardian Name_________________________________________________ Have you been to FACE before? Y N

Address_____________________________________________ City__________________________ Zip Code____________

    Phone(1)___________________ Phone(2)___________________ E-mail Address____________________________________

    Have we seen this dog before? ____________________ Do you have other pets at home? ____________________

How did you hear about FACE? (circle) Family Friend Internet Phonebook Other


    Please answer the following as completely as possible. The answers provided will allow us to better serve both you and your dog. Should you require assistance, please ask a representative.

    How long have you had this dog/cat? ___________________________________

Is he/she neutered? (circle) YES NO

    (For female dogs) Is it possible that she may be pregnant? (circle) YES NO

    Does he/she seem healthy to you? YES NO If you answered NO, please explain: ______________ _________________________________________________________________________

Approximate date of last vaccines __________________

    Date of last heartworm test _________________ Result: (please circle) NEGATIVE POSITIVE

    Is your dog currently taking Heartworm Preventative? (circle) YES NO

    Has your dog bitten anyone in the last 10 days? (circle) YES NO

Has your dog ever had a reaction to vaccines? ________________________

Does your dog get carsick? __________________________________

    How many other cats/dogs do you have at home? ______________________________

    Where do your cats/dogs stay? (circle) INSIDE OUTSIDE BOTH

_________________________________ _______________

    Client Signature Date

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