Animal Health Clinic - Decline to Immunize Form

1

The purpose of any immunization program is to effectively reduce the danger of infectious diseases to our pets.

2

Owner info

Name

Email

Phone Number

3

I understand that my pet

may be exposed to the diseases(s) indicated on the Disease-Risk Assessment Form.

has a chance of contracting this (these) disease(s).

4

I understand that immunization of my pet

will substantially reduce, but may not completely eliminate, the chance of my pet contracting this (these) disease(s).

5

I have had the opportunity to ask any questions I have concerning this (these) immunizations(s). All such questions have been answered to my satisfaction.

6

Vaccines you are choosing to decline***Rabies Vaccine may not be declined!***

Canine Distemper/Canine Parvovirus (combined in one vaccine)

Canine Leptospirosis

Canine Influenza

Bordatella

Feline Leukemial Rhinotracheitis / CalicilPanleukopenia /Chlamydia Psittaci (combined in one vaccine)

7

I have been informed of, and understand, the risks associated with non-immunization and decline to vaccinate my pet.

8

Pet Name

9

Signature

Clear

10

Date