$10 Exam Fee Fredericksburg Road location only. You re number: Please wait to be called. Color Pattern

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Rosa Stewart
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1 San Antonio Humane Society 4804 Fredericksburg Road San Antonio, TX SAhumane.org Brooks Spay/euter Clinic 8034 City Base Landing San Antonio, TX SAhumane.org/Brooks Thank you for choosing the San Antonio Humane Society (SAHS) as your pet s low-cost wellness provider. Please fill out the following forms and waivers to the best of your ability. If you have any questions, please ask your Animal Health Technician for assistance. $10 Exam Fee Fredericksburg Road location only ou re number: Please wait to be called. Client/our ame Address City/State/Zip Primary Phone #_ Date_ Pet s ame Species (circle one): DOG CAT Sex (circle one): M F Spayed/eutered (circle one): ot Sure Age Breed Weight_lbs. Color_ Color Pattern Please continue to the form on the reverse side of this page. 1

2 Client ame Pet ame Date_ Wellness Service Consent Form Please read below carefully and intial inidicating you have read and agree with each one statement. I understand that the San Antonio Humane Society (SAHS) offers preventative services only. I understand that the veterinarian or animal health technician examining the pet will refer me to a full-service veterinary clinic for any additional services the pet may require outside the scope of the SAHS Wellness Clinics. I understand that the veterinarians and animal health technicians of the SAHS may refuse to provide services to the pet if they feel the pet s health will be compromised, or if the pet poses a danger to itself or to others. I understand that any vaccine or injection administered has a risk of causing a reaction (local or systemic) even if the pet is healthy. I understand that the SAHS veterinarians nor its staff are liable for vaccine reactions that may occur. Texas Health and Safety Code b. requires the San Antonio Humane Society (SAHS) to verify and document the following information in order for our veterinarians to provide services to the general public. I certify that I qualify for wellness services according to the following criteria (please check all that apply): I receive government assistance. My gross annual household income is less than $21,000. I am otherwise unable to afford preventative veterinary services for my pet. Signature Date_ 2

3 Client ame Pet ame Date_ Vaccine Reactions Every vaccine stimulates the immune system to be effective. Sometimes vaccines over-stimulate the immune system causing the body to react negatively to the vaccine or its components. This over-stimulation can cause a vaccine reaction. The veterinarians at the SAHS would like you to know what symptoms to possibly expect after your pet receives a vaccination. COMMO SMPTOMS: responses to vaccines (symptoms should only last hours) -Low-grade fever (less than 103 o F ) -Mild soreness at the sight of vaccine injection -General soreness If any of these symptoms last longer than 48 hours, please see your primary care veterinarian. OCCASSIOAL SMPTOMS: Mild to moderate vaccine reactions (usually occur within the first 24 hours after vaccination) -Facial swelling or hives on the body -Vomiting and/or diarrhea -Severe lethargy (drowsiness) -Abnormal discomfort or soreness UCOMMO/RARE SMPTOMS: Severe vaccine reactions (usually occur immediately after vaccination) -Collapse -Shock -Difficulty breathing If your pet has previously suffered a severe reaction to a vaccine, you must have your pet vaccinated at a full-service veterinary clinic. The San Antonio Humane Society is not equipped to treat severe vaccine reactions. Our wellness clinics are designed to provide streamlined service for healthy pets in need of regular immunizations and preventative care. A pet with a vaccination reaction history requires special attention by observation in a veterinary hospital and pre-treatment with medications prior to being vaccinated. If your pet has a severe reaction, our veterinarians are legally authorized to provide basic life support treatment only. our primary care veterinarian must administer any additional care at a full-service veterinary clinic. By signing below, you indicate that you have fully read and understand the above information on vaccine reactions. Signature Date_ Heartworms are spread by mosquitos. It is essential to keep your dog on monthly heartworm prevention to prevent this deadly disease. Give your pets monthly heartworm, flea, and tick prevention for their best health! Remember to spay/neuter your pets! Puppy and Kitten Packages: Puppies over the age of 15 weeks are not eligible for these packages. Boosters are recommended to be administered every 3-4 weeks until the pet has received a total of three boosters. We recommend all large breed puppies be vaccinated every 3-4 weeks until the pet is six months of age. 3

4 Client ame Pet ame Date_ Vaccinations and Services Please check the vaccinations and/or services you request for your pet. Depending on your pet s health evaluation, he/she may or may not qualify for the requested vaccinations/services. If you have any questions please consult your Animal Health Technician. DOG DAPP Vaccine...$20.00 (Distemper, hepatitis, flu, and parvo vaccine) Bordetella Vaccine...$12.00 Rabies Vaccine...$11.00 Puppy Package...$36.50 ($31.50 for litters) (DAPP, nail trim, dewormer, sample heartworm & flea prevention) Puppy Booster Package...$31.50 ($26.50 for litters) (DAPP, nail trim, dewormer) Basic Annual Package...$28.50 (DAPP & Rabies) Doggone Best Package...$60.00 (DAPP, Rabies, Bordetella, heartworm test) Heartworm Test...$21.00 Heartworm 4DX Test...$37.00 $10 Exam Fee Fredericksburg Road location only Packages are not available for substitution or exchanges. All combinations are available as is only. Samples are available while supplies last. Puppy and Kitten Packages: Puppies over the age of 15 weeks are not eligible for these packages. Boosters are recommended to be administered every 3-4 weeks until the pet has received a total of three boosters. We recommend all large breed puppies be vaccinated every 3-4 weeks until the pet is six months of age. Litter discounts are only applicable for pets in the same litter, of the same age, and when more than one pet is present. Booster packages are only available to animals who have received their previous vaccine(s) in an appropriate time frame (3-4 weeks) with the SAHS. ou must provide records at the time of visit. CAT FVRCP Vaccine...$17.00 (prevents common untreatable respiratory diseases) Rabies Vaccine...$11.00 Kitten Package...$36.50 ($31.50 for litters) (FVRCP, nail trim, dewormer, sample flea prevention) Kitten Booster Package...$31.50 ($26.50 for litters) (FVRCP, nail trim, dewormer) Basic Annual Package...$26.50 (FVRCP & Rabies) FeLV/FIV Combo Test...$31.50 (Brooks location only) ADDITIOAL SERVICES Dewormer (Pyrantel < 6mo.)...$5.00 Dewormer (Pyrantel > 6mo.)...$10.00 Dewormer (Triwormer - Canine)...$6.00/tab Dewormer (Biwormer - Feline)...$10.00/dose Dewormer (Praziquantel Injection)...$10.00/dose Microchip...$27.00 ail Trim...$15.00 Prevention Single 6-Pack QT Prevention Single 6-Pack QT Prevention Single 6-Pack QT 0-25 lbs $5.50 $33.00 exgard lbs $15.75 $94.50 Adv. Multi Blue lbs lbs $6.50 $39.00 exgard lbs $16.25 $97.50 Adv. Multi Brown lbs lbs $7.75 $46.50 Adv. Multi Green 3-9 lbs dogs & cats < 5 lbs $11.50 $69.00 exgard 4-10 lbs $15.25 $91.50 Adv. Multi Teal lbs cats 5-15 lbs $12.50 $75.00 exgard lbs $15.50 $93.00 Adv. Multi Red lbs cats lbs $12.75 $76.50 Heartworms are spread by mosquitoes. It is essential to keep your dog on monthly heartworm prevention to prevent this deadly disease. Give your pets monthly heartworm, flea, and tick prevention for their best health! Remember to spay/neuter your pets! 4

5 Client ame Pet ame Date_ OFFICE USE OL 5

6 Client ame Pet ame Date_ Medical Record Pre-Exam Questionnaire For every patient seen, the technician should ask the following questions. The answers will help determine what is in the best interest for the pet. General Eating/drinking well? Vomiting and/or diarrhea? Coughing and/or sneezing? If yes, how often? Are there any allergies, and are they seasonal (spring/summer)? Has the pet ever had a vaccine reaction? Heartworm Prevention Is the pet on heartworm prevention? If no, when was the last dose given, if ever? Discuss heartworm test and prevention. Flea/Tick Prevention Is the pet on flea/tick medication? Does the owner see a lot of ticks on the pet? If yes, recommend the 4DX heartworm test to test for tick-borne diseases. Make sure to recommend exgard. Advantage Multi and do not prevent ticks. Bordetella Vaccination Does the pet go to the groomers, a boarding facility, or the dog park? If yes, discuss the Bordetella vaccine and have the owner consider it. Has the pet received a Bordetella vaccine before? If yes, when was the last vaccine adminstered? Recommend the vaccine every 6-12 months, dependent upon visit frequency to the groomers, boarding facility, dog park, etc. Puppies/Kittens When did the person acquire the pet? Where did the person get the pet from (friend, breeder, shelter, etc.)? Has the pet ever received any vaccinations, including from the previous owner? If yes, when and what was the last vaccine? What is the pet being fed and how often? When was the last time the pet ate? Please inform clients that all puppies need to be kept indoors until fully vaccinated at 4-5 months of age. The pet needs at least 3 or 4 DAPP vaccinations and 1 rabies vaccination at 4 months of age. 6

7 Client ame Pet ame Date_ Wellness Clinic Exam Form Vet/Tech ame Pet Weight General Appearance/Attitude Hydration Skin/Coat Circulatory System Gastrointestinal System Respiratory System ose/throat Musculoskeletal Eyes Ears Mouth/Teeth/Gums Urogenital System ervous System Other Other Other Other Other Other Other Other Other Other Other Other Other our pet s next vaccinations/tests are due: Please see your regular veterinarian for the following concerns: Rabies DAPP FVRCP Services rendered and results: Bordetella Heartworm test Heartworms are spread by mosquitoes. It is essential to keep your dog on monthly heartworm prevention to prevent this deadly disease. 7

8 Client ame Pet ame Date_ DOG DAPP Vaccine...$20.00 Bordetella Vaccine...$12.00 Rabies Vaccine...$11.00 Services Rendered Puppy Package...$36.50 ($31.50 for litters) (DAPP, nail trim, dewormer, sample heartworm & flea prevention) Puppy Booster Package...$31.50 ($26.50 for litters) (DAPP, nail trim, dewormer) Basic Annual Package...$28.50 (DAPP & Rabies) Doggone Best Package...$60.00 (DAPP, Rabies, Bordetella, heartworm test) Heartworm Test...$21.00 Heartworm 4DX Test...$37.00 Prevention 0-25 lbs lbs lbs exgard 4-10 lbs exgard lbs exgard lbs exgard lbs Adv. Multi Green 3-9 lbs Adv. Multi Teal lbs Adv. Multi Red lbs Adv. Multi Blue lbs Adv. Multi Brown lbs dogs & cats < 5 lbs cats 5-15 lbs cats lbs Single $5.50 $6.50 $7.75 $15.25 $15.50 $15.75 $16.25 $11.50 $12.50 $ Pack $33.00 $39.00 $46.50 $91.50 $93.00 $94.50 $97.50 $69.00 $75.00 $76.50 QT CAT FVRCP Vaccine...$17.00 Rabies Vaccine...$11.00 Kitten Package...$36.50 ($31.50 for litters) (FVRCP, nail trim, dewormer, sample flea prevention) Kitten Booster Package...$31.50 ($26.50 for litters) (FVRCP, nail trim, dewormer) Basic Annual Package...$26.50 (FVRCP & Rabies) FeLV/FIV Combo Test...$31.50 (Brooks location only) ADDITIOAL SERVICES Dewormer (Pyrantel < 6mo.)...$5.00 Dewormer (Pyrantel > 6mo.)...$10.00 Dewormer (Triwormer - Canine)...$6.00/tab Dewormer (Biwormer - Feline)...$10.00/dose Dewormer (Praziquantel Injection)...$10.00/dose Dewormer dose Microchip...$27.00 ail Trim...$15.00 Heartworm test result: Positive Heartworm 4DX test results Heartworm: Positive egative Lymes: Postitive egative Ehrlichia: Positive egative Anaplasma: Positive egative FeLV/FIV Combo test result: Positive Microchip Sticker Microchip Company 24PetWatch DHPP Bordetella FVRCP Rabies egative 8 egative

9 Client ame Pet ame Date_ Office Use Only Total Due $ Payment Method: Credit/Debit Cash Check Staff Initials Medical Entered: Person s PetPoint # Animal s PetPoint # Date Entered Staff Initials 9

Annual Dog Package - $80

Annual Dog Package - $80 Physical Exam ($25) Rabies Vaccine ($14) DHLPP Vaccine ($16) (Distemper/ Parvo/Lepto) Heartworm Test ($22) Fecal Test ($15) Bordatella Vaccine ($14) *MANDATORY $20 PET REGISTRATION