EmailMeForm
Vaccination Request Form
Please complete the form below, one form per animal
Date:
*
MM
/
DD
/
YYYY
Owner Information:
Name:
*
First
Last
Primary Phone:
*
###
-
###
-
####
Physical Address:
*
Street Address
City
State / Province / Region
Postal / Zip Code
Email:
*
Animal Information:
Animal Name:
*
Age:
*
Weight:
*
Breed:
*
Gender:
*
Male
Female
Spayed/Neutered:
*
Yes
No
Primary Color:
*
Please select
Black
Brindle
Brown
Calico
Golden
Gray, Blue or Silver
Merle
Red
Tan
Tricolor
Yellow
White
Secondary Color:
Please select
Black
Brindle
Brown
Calico
Golden
Gray, Blue or Silver
Merle
Red
Tan
Tricolor
Yellow
White
Did you adopt your pet from LPCHS?
*
Yes
No
Has your pet ever received vaccinations from LPCHS?
*
Yes
No
Unsure
Is your pet microchipped?
*
Yes
No
Vaccination Requests:
Please select all vaccinations you would like your pet to receive:
*
Canine Booster (DA2PPV): Distemper, Adenovirus Type 2, Para Influenza and Parvovirus - $25.00
Bordetella (Kennel Cough) - $25.00
Feline Booster (FVRCP): Rhinotracheitis, Calicivirus, Panleukopenia, Chlamydia - $25.00
Microchip - $45.00
Dewormer for Tapeworms - $20.00
Has you pet ever had a bad reaction to a vaccine?
*
Yes
No
Is your pet on any medication at this time?
*
Yes
No
If yes, what?
COVID-19 Disclaimer:
*
I understand a team member will call me to schedule an appointment. Walk-ins are subject to denial.
*
I understand payment is due over the phone when appointment is scheduled.
*
I understand my pet will receive their vaccinations outside of the shelter. If a shelter team member is unable to administer the vaccine(s) outside, my pet is only allowed inside of the shelter.
