First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Cell Phone*

Alt Email*

Pet's Name*

Pet's DOB*

Pet's Microchip #

Species

I, the undersigned owner of, agent of the owner of, or Good Samaritan responsible for seeking veterinary care/services for the pet identified above, certify that I am over 18yoa. I Authorize my pet to receive the above care. I understand United For Animals Rescue is a 501c(3) rescue shelter and low cost clinic that do not offer full service veterinary assistance or procedures, only basic care/services to help the community. I will not hold United For Animals Rescue accountable any of for the above services described and I am responsible for the cost of all the boxes checked.

Please check the boxes that apply for your pet today's visit
Choose all that apply: Vet Check Up(Optional) - $35 Dog 5-in-1 Vaccine (DA2P + Parvovirus) - $30 Dog Bordetella Vaccine - $30 Dog Heartworm Test - $40 Cat 3-in-1 Vaccine (FVRCP) - $30 Rabies Vaccine - $30 Cat Feline Leukemia Vaccine (FeLV) - $40 Intestinal Parasite Screening - $30 Cat Feline Retroviral Test (FeLV/FIV) - $35 Microchip - $25 Nail Trim - $15 Deworming (single dose) - $25 Tapeworm Treatment(based on weight - $40

Testing Results (VET ONLY)

Additional Comments (VET ONLY)