Vaccine Clinic

Animal Medical Hospital
& Bird Clinic
&
Whitestone
Veterinary Care

The Animal Medical Hospital & Bird Clinic

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Animal Medical Hospital will host a vaccine clinic: Saturday, January 7, 2012, 2-5pm. This event will be a first come first serve basis.

All patients will receive a pre-vaccination examination to confirm they are healthy enough to get vaccines. Please be advised that our clinic reserves the right to deny vaccines to pets that are deemed unhealthy or unwell at the time of the vaccine clinic. In these cases our doctors may advise you to schedule a compressive examination during normal office hours.

There are a small percentage of pets that have allergic reactions to vaccines. Please advise the veterinarian if your pet has had a previous vaccine reaction. Signs of reaction can include facial swelling, hives, labored breathing, and/or vomiting.

Form - Health Questionnaire Form

Client Information

Name (required)
First Name (required)	Last Name (required)

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Main Phone (required)
Phone Type	Phone Number (required)

Secondary Phone (required)
Phone Type	Phone Number (required)

E-Mail Address

E-Mail Address (required) :

Pet Information

Pets Name (s) (required)

Breed (required)

Age (s) (required)

Sex (required)
Male
Female
Neutered Male
Spayed Female

Is your pet: (required)
Indoors Only
Outdoors
Indoor/ Outdoor

Pet Health Questionnaire

Has your pet been bitten or bitten another pet or human with in the last 10 days? (required)
no
yes

Does your pet have a decreased appetite? (required)
no
yes

Has your pets bowel movements changed in consistency or frequency? (required)
no
yes

Is your pet drinking an abnormal amount of water? (required)
no
yes

Is your pet urinating abnormally? (required)
no
yes

Is your pet sluggish/ lethargic? (required)
no
yes

Is your pet frequently coughing? (required)
no
yes

Is your pet abnormally sneezing? (required)
no
yes

Does your pet have nasal discharge? (required)
no
yes

Has your pet vomitted in the past week? (required)
no
yes

Has your pet been severely scratching him/herself? (required)
no
yes

Have you seen any fleas or ticks on your pet? (required)
no
yes

Does your pet have any abnormal lumps/masses that have grown in size? (required)
no
yes

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