Medical Information
Veterinarian's
Name __________________________________________________
Hospital
____________________________________________________________
Hospital
Address ____________________________________________________
___________________________________________________________________
Phone
Number ______________________________________________________
Dates:
Last
Physical Exam __________________________________________________
DHLPPC
(or the equivalent) ____________________________________________
Rabies
Vacc ___________________________ 1 yr. or 3 yr. __________________
Bordatella
___________________________________________________________
Heartworm
Test ______________________________________________________
Heartworm
Prevention _________________________________________________
Last
Purchase Date ___________________________________________________
Flea
Prevention _______________________________________________________
Last
Purchase Date ____________________________________________________
The
above medical information is true to the best of my knowledge.
_____________________________________________________________________
Veterinarian's
Signature
In
the event of an emergency Cleveland MetroBark has permission to
transport
_________________________________ to the above vet (or the closest reliable
vet) if necessary.
Payment
arrangements are to be made between owner and veterinarian in advance.
________________________________________
______________________
Owner's
Signature
Date