Vaccine Clinic Form

Pet Details

Owner Details

Form Details

Has your pet ever had any reactions to vaccines in the past?

If my pet has experienced a vaccine reaction in the past, I understand that this clinic can NOT administer vaccines to my pet and that I will have to schedule an appointment with a full service clinic so that extra pre-cautions can be taken to prevent a reaction in my pet.

Please select which services your pet will need for their visit.

For the check in process to be efficient and on time, please show up at your exact appointment time and do not arrive early or late. We are a high volume clinic and to manage a high volume of animals and clients checking in it is imperative for everyone to show up at their exact appointment time. Arriving early will not mean you will be seen early, you will have to wait until your appointment time to be seen and arriving late will mean that your appointment will have to be worked in and possibly be seen after all other appointments are checked in.

By signing below, I confirm that I am at least 18 years of age, and as the legal owner of this pet, give the Arizona Humane Society, its veterinarians, employees, volunteers, representatives, or agents, authorization to receive, vaccinate, prescribe for, treat, and operate upon your pet. I understand and acknowledge that the Arizona Humane Society uses modern techniques and trained staff in the care of my pet(s) and that reasonable precautions are used to prevent escape or injury to the animal or the handler(s). I understand that the limited physical examination the veterinarian will perform today is used solely to determine whether or not the patient appears healthy enough to receive vaccines. This exam is not meant to replace an annual complete physical exam, and will not include testing my pet for any diseases or diagnosing/treating my pet for any past, current, or future condition. The veterinarian cannot address medical issues unrelated to the administration of vaccines at this time. I further understand that the attending veterinarian may refuse to administer vaccinations if he/she believes it may endanger my pet's health in any way.
I understand and acknowledge that an adverse reaction to vaccine(s) may occur that would require medical intervention by the staff veterinarian. If additional treatment is needed beyond the initial intervention, I acknowledge that I am responsible for transporting my pet to a private veterinary clinic. I agree to pay all reasonable charges for procedures deemed necessary by the attending veterinarian to maintain a reasonable quality of life for my pet in this instance. I acknowledge that less immediate complications can also arise and that I will receive aftercare instructions.
I will be informed of any changes in the proposed care and treatment of my pet, as well as any change in the condition of my pet. If I cannot be reached and/or an emergency situation arises, the hospital doctor(s) and staff are to use sound medical judgment in caring for my pet. I am to be informed of the discharge date for my pet, and will be expected to pay all charges in full upon the release of my pet.

• I acknowledge that my pet has no known medical conditions, including pregnancy, which would prevent him/her from receiving a vaccination today.
• I understand that the Arizona Humane Society recommends that all cats be tested for Feline Leukemia Virus and Feline Immunodeficiency Virus. I understand that if my cat is already infected with one or both of these diseases, the vaccination he/she receives today is not a treatment or cure for any pre-existing condition.
• To my knowledge, my pet has not previously had an adverse reaction to a vaccine or medication. If my pet has experienced a vaccine reaction in the past, I understand that this clinic can not administer vaccines to your pet and that I will have to schedule an appointment with a full service clinic so that extra pre-cautions can be taken to prevent a reaction in my pet.
Vaccine reactions, although rare, can sometimes occur. The protection against disease that vaccines provide far outweighs the potential risks associated with vaccination. You should consider scheduling your pet's vaccinations for a time when you can spend several hours with your pet following vaccination. By being able to observe your pet during this time period, you would be able to contact a veterinarian if complications arise. Your pet may be slightly lethargic, have a decreased appetite, scratch at the injection site, and/or run a slight fever for the first 24-72 hours after receiving vaccines. Rarely, a more serious reaction can occur. Symptoms of a more severe vaccine reaction may include:
1. Severe and prolonged salivation, vomiting and/or diarrhea.
2. Skin hives, facial swelling, etc.
These more serious vaccine reactions usually occur within a matter of minutes to a few hours following vaccination. If any of these occur, your pet needs to be seen by a veterinarian as quickly as possible, as these symptoms can progress to trouble breathing and heart trouble, and can be life-threatening. With veterinary attention, these side effects can usually be reversed. A fairly common finding after receiving a vaccine can be a small, marble-sized mass at the injection site. This is most commonly seen in association with rabies vaccines but can occur after any injection. As long as there is no overt pain or discharge, this side effect is not considered dangerous. This lump can sometimes persist for up to 3 months. If it is painful, has a discharge, gets bigger than a large marble, or lasts longer than 3 months, please call your veterinarian to schedule an appointment to have the lump examined. If you are concerned about your pet's reaction to its vaccination, please call the clinic that you visited. If it is after hours, we have limited veterinary coverage, so please call an emergency animal clinic or take your pet to the closest open veterinary clinic.

By signing below, I confirm that i have fully read, understand, and agree to these conditions.


Please sign electronically below.

Your browser does not support the signature

Click submit and you hereby give consent to sign this document electronically.

Sending data