Beautiful Hearts Rescue Vaccine Clinic

October 14, 2023

PLEASE READ AND CONSENT TO THE FOLLOWING:

I am the owner or authorized agent of the animal(s) listed and consent to have the above services performed.
My animal(s) is/are not pregnant and do not have a chronic medical condition.
My pet is currently healthy and has not shown signs of illness (coughing, sneezing, vomiting, diarrhea, lethargy, loss of appetite, fever, etc.) within the past 14 days.
My pet has no history of having an adverse reaction to vaccinations.
I agree to hold Beautiful Hearts Rescue and Horse Sanctuary, Ltd., its employees and affiliates free and harmless from any and all illness and/or injuries sustained and/or loss incurred by pet owners or pets during, prior to, or after the vaccine clinic. Should my animal(s) become ill due to vaccines, I agree to treat any medical concerns/conditions or vaccine reactions at my own veterinarian or emergency clinic, and this will be my financial responsibility. I am aware such reactions are possible, though they are rare.
I understand that this is not a full and complete exam. A comprehensive exam should be performed at least yearly at my local veterinarian.
I understand that records will be emailed to me after the event. If I do not receive the email I can contact Beautiful Hearts Rescue and ask for duplicate copies to be sent by sending an email to beautifulheartsanimalrescue@gmail.com

Signature(Required)

Date(Required)

Please Fill Out Completely

Pet‘s Owner (Full Name):(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Did you attend last year’s clinic?(Required)

Yes

Amount of Animals

Please, choose the amount of animals that will be registered

Animal 1

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 2

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 3

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 4

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 5

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 6

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 7

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 8

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 9

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 10

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 11

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 12

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 13

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 14

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Animal 15

Pet’s Name:(Required)

Animal(Required)

Dog

Cat

Horse

Sex(Required)

Male

Female

Pet’s DOB:(Required)

Pet’s Breed:(Required)

Pet’s Color:(Required)

Spayed/Neutered(Required)

Spayed

Neutered

Based on your records did this pet attend last year’s clinic?(Required)

Yes

VACCINES REQUESTED

Rabies:(Required)

Yes

Tag #:(Required)

Verified 3 year eligible(OFFICE USE ONLY)

Yes

Animal specific core vaccines:(Required)

Yes

Would you like us to Microchip your pet today for FREE?(Required)

Yes

Microchip Number:(OFFICE USE ONLY)

Do you want any extra services today?(Required)

Yes

Extra services have a fee and may require boosters to be effective.

We can process credit cards

List

Lyme Vaccine – Requires booster in 3 weeks. Fee of $15.00 per vaccine

Bordetella Vaccine – No booster required. Fee of $5.00

Leptospirosis – Requires booster in 3 weeks. Fee of $3.00 per vaccine

6 months of Flea/Tick preventative (simparica Trio) $100

Dog weight

List2

1 month of Flea/Tick preventative (Simparica Trio) $17

Please let us know if any of the below apply.

Help

I need help feeding and providing vet care for my animal.

Care

Feeding only

Vet care only

Contact

May we contact you to see if we can offer support?