Shots application

Application for shots

Hooks Home Bound Rescue can assist you in finding low cost shots for your pet. In doing so, we voluntarily reach out to low cost clinics and veterinarians. Hooks Home Bound Rescue takes no responsibility for the clinic or veterinarian office. The following form is to be filled in completely so we know what shots you are requesting for your pet.

Name*

Phone #

(include area code)

address *

number street city state and zip code

Email Address*

Has your pet had shots before

yesno

last date of shots

My pet is a *

catdog

Pet name*

breed of pet*

pet age*

Pet weight*

My pet has allergies to medications*

noyes

I am requesting the following shots for my dog

Rabies (Required for dog license. Must be 4 months or older)DA2pp+cv(Distemper, Parvovirus, Parainfluenza, Adenovirus type 2 + Corona Virus - for dogs 6 weeks to 6 months)DA2PP (Distemper, Parvovirus, Parainfluenza, Adenovirus type 2 - for dogs 6 months+)Bordetella (to protect against kennel cough – 8 weeks or older)Lepto (optional but highly recommended for any dog that commonly goes outside, even just to go to the bathroom in the backyard.)Rattle Snake Shot ((gives you more time to get medical attention after getting bit by rattlesnake – 4 months or older

I am requesting the following shots for my cat

RCP (Rhinotracheitis, Calici, Panleukopenia – 8 weeks or older)RCPC (RCP w/Chlamydia Psittaci – 10 weeks or older)RCPC with Leukemia (RCPC w/Leukemia – 10 weeks or older)Rabies

Disclosure agreements- check if you agree to the following*

I agree Hooks Home Bound Rescue will do everything they can to assist in my need for shots.I agree to hold Hooks Home Bound Rescue harmless of any referral they may set up for me with a veterinarians.I agree to permit Hooks Home Bound Rescue to release my information (any of the above) to Veterinarians so they can set up appointments for me and my pet.

Permissions- Check all that apply*

I authorize Hooks Home Bound Rescue to set up appointments for my pet.I authorize Hooks Home Bound Rescue to contact me about this application.I authorize Hooks Home Bound Rescue to use the following printed name as my authorized signature.

Print your Name in full*

Todays Date is*

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