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Wellness Consent Form
Wellness Consent Form
Date Format: MM slash DD slash YYYY
Your pet's name
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 agree to consent?
I have read the wellness services consent form, and I understand and agree to its contents.