Wellness Clinic Registration Owner's Name:* First Last Owner's Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner's Phone Number:*Owner's Email Address:* Pet's Name:*Pet's color/markings and breed (if known):*Type of Animal* Dog Cat Other Pet's Age*Pet's Gender:* Male Female My pet is... (choose all that apply)* Fixed (spayed or neutered) Microchipped Neither/Unknown Reason for wellness clinic visit:*Please check all vaccinations/tests that your dog has received within the past 12 months* Rabies Distemper (DHLPP) Bordetella (Kennel Cough) Heartworm Test None of the above Please check all vaccinations/tests that your cat has received within the past 12 months* Rabies Distemper (FVRCP) Feline Leukemia/FIV Vaccine (FELV) None of the above What is your pet's medical history? (surgeries, ongoing medical issues, coughing, vomiting, allergies, seizures, etc.)*Is your pet on flea prevention?* Yes No Is your dog on heartworm prevention?* Yes No Has your pet ever had a vaccine reaction?* Yes No Does your pet need muzzled for vet care?* Yes No Has your pet ever bitten?* Yes No If your pet has bit, please describe (person, animal, situation, etc)*Do you have other pets or do you foster other pets?* Yes No If other pets live in the home, please list them:*Is your pet currently taking any medications? (including heartworm/flea medication)* Yes No Please list the medications:*Has your pet been seen by a veterinarian?* Yes No If they have seen a vet, whom and reason for visit(s):*Wellness Clinic Agreement* Please check this box if you agree to the policy below:I authorize the Lake Humane Society (including its employees and agents) to provide care and perform any treatment it considers reasonable or necessary for the animal, and I consent to any such services. I understand that with any medical or surgical procedure there are always risks involved, including death, and that no guarantee is being made as to the results or cure. I hereby release LHS, its veterinarians, assistants, volunteers, employees, directors or board members from any claims arising out of, or connected with the performance of this procedure or any adverse reactions from vaccinations. I, being lawfully authorized to make decisions on behalf of the animal named above hereby request LHS, including its affiliates and employees, volunteers, veterinarians, and/or other agents to receive, transport, prescribe for, treat, and/or administer vaccinations and/or medications.Signature (type your full name below)*Today's Date* MM slash DD slash YYYY If your pet has vet records, please upload them here: Drop files here or Select filesMax. file size: 10 MB.