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Wellness – Robbinsville
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Wellness – Robbinsville
Robbinsville Wellness Appointment Request
THIS APPLICATION IS A REQUEST ONLY FOR AN OFFICE VISIT APPOINTMENT. Our staff will confirm your appointment by email by the end of the next business day. If your need cannot wait, please call the clinic to schedule your appointment.
Robbinsville - Wellness
Name
*
First
Last
Address
*
Street Address
Address Line 2
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State
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Cell Phone
*
Home Phone
Email
*
Have you or anyone living in your home had Covid-19 or been exposed to someone with confirmed or suspected Covid-19 in the last 14 days?
*
Yes
No
Please call the clinic at (609) 208-3252.
Your pet's name
*
My pet is a...
*
Cat
Dog
Your dog's breed
*
Your cat's breed
*
Your dog's color
*
Your cat's color
*
What sex is your dog?
*
Male
Female
What sex is your cat?
*
Male
Female
Your dog's age (please specify months or years)
*
Your cat's age (please specify months or years)
*
Is your pet sick? Or do you need one of the following services – Rabies or Leptospirosis vaccination, deworming, or puppy/kitten vaccinations.
*
My pet is sick
I need one or more of the above services
None of the above
Please call the clinic at (609) 208-3252.
Does your pet need spay/neuter as part of the treatment for an illness?
*
Yes
No
We will call you today at the phone number(s) you provided to schedule your appointment.
Please describe your pet's symptoms
*
Product Name
What service(s) would you like?
*
Rabies Vaccination
Leptospirosis Vaccination
Deworming
Puppy Vaccination (Distemper)
Does your dog also need any of the following services?
*
Bordetella Vaccination
Canine Flu Vaccination
Lyme Vaccination
Heartworm/Lyme/Anaplasmosis/Ehrlichiosis Test
Fecal Test
Microchip
None
What service(s) would you like?
*
Rabies Vaccination
Deworming
Kitten Vaccination (Distemper)
Does your cat also need any of the following services?
*
Leukemia Vaccination
Fecal Test
Microchip
Revolution - Single Application
None
Would you like to make a donation?
*
We rely on the generosity of our supporters to keep our fees affordable.
$5 donation
$10 donation
$25 donation
$50 donation
None
Office Visit Fee
*
I understand there is an office visit fee
Your total is
$0.00
The goal of animal vaccination is to effectively reduce the extent and severity of infectious diseases in our pets. In granting this consent to treat and vaccinate, I hereby state that: My pet(s) is healthy with no known allergies to vaccines and has had no recent occurrences of abnormal coughing, sneezing, vomiting, diarrhea or weight loss. My pet has not bitten or scratched anyone in the last 10 days. I have disclosed all medication my pet may be taking. I have disclosed any other health issues known to me about my pet. I understand that, because the causes of Kennel Cough are numerous and varied, the Bordetella vaccine cannot protect my dog from every possible infectious agent. While this vaccine cannot prevent my dog from contracting Kennel Cough, it will help protect against a cause of Kennel Cough pneumonia, Bordetella brochiseptica. I understand that my pet(s) may be exposed to the diseases that the vaccinations which I have purchased are intended to protect against. I understand that vaccination of my pet(s) substantially reduces, by may not completely eliminate, his/her chances of contracting the diseases the vaccinations intend to protect against. I understand that my pet(s) may develop adverse reactions to vaccination. I understand that these adverse effects are usually minor and will usually resolve without the need for additional veterinary intervention. I understand that should my pet develop any severe or unanticipated reaction to the vaccination, I should seek emergency care immediately. I understand that all charges for any such treatment are my own financial responsibility. I understand that People for Animals, Inc. uses quality vaccines and medications from major pharmaceutical manufacturers. I accept that adverse reactions are highly individual immune responses which cannot be foreseen. Should it happen that my pet becomes ill as a result of vaccination or treatment, I will not hold the veterinarian or People for Animals, Inc. responsible. I further understand that all medical care for any complications are at my own expense. I understand and accept that my cat(s) have approximately 1 chance in 44,000 of developing a sarcoma (a type of tumor) at the vaccination site. I understand that this type of tumor, should it occur, is life threatening and may require extensive medical or surgical treatment. It is unknown what causes this type of reaction at the injection site. I understand that People For Animals, Inc. makes no warranty, either express or implied, as to the safety or efficacy of the vaccines or medications being used. I acknowledge that a complete physical exam has not been performed. My pet(s) has been assessed for appropriateness for vaccination and any other treatment. I had an opportunity to ask any questions I have concerning vaccinations and treatments. All such questions have been answered to my satisfaction. I am aware that People for Animals Inc. is a non-profit organization with a mission to eliminate pet overpopulation which leads to the unnecessary death of thousands of animals in shelters every year. I understand that a surcharge is payable to People for Animals, Inc. if my pet has not been altered and is 6 months of age or older. I understand that a surcharge is payable to PFA if I present the offspring of my pet for low price vaccinations or other routine juvenile treatment and it is determined that I have intentionally bred my pet and/or intend to continue to do so. I authorize PFA to release my name and contact information as needed to register a microchip or to determine disposition and ownership of an animal in which a microchip registered to me has been discovered. I understand that my pet may be treated by a non-licensed veterinary student under the direct supervision of a licensed veterinarian, Laurie Heeb, DVM.
Have you read and agreed to the consent?
*
I have read the wellness services consent form, and I understand and agree to its contents.
View Consent
Signature
*
