HARQUAHALA KENNELS.PDF

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Maricopa County
Animal Care And Control
2500 South 27th Avenue
Phoenix, AZ 85009
(602) 506-7387 Tele.
(602) 506-2739 Fax
KENNEL PERMIT APPLICATION
LI New 156 Renewal Permit -• 0060 lE
Name: Aigli fii&k-.14,"( Kennel Name: -1Ar E0444,4- 4-AMMI 9
Mailing Address:/O(. 19- '54'C Kennel Location:1 66:b.)-36-1-6Age.---77-irtcf
City ')0,41-. /) /47 ZIP 3-CY- --7)-3c6ounty Supervisorial District _
,
Kennel Phone: Clc;21 —
Please complete and sign this application and return it to the above address with payment in the amount of three
hundred twenty eight dollars ($328.00) within ten (10) days of receipt.
Pursuant to Arizona statute and county ordinance, a person must obtain a kennel permit issued by the Board of
Supervisors if the person operates a kennel in which there are five or more dogs which are not individually
licensed. A.R.S. §11-1009(A). A kennel is defined as "an enclosed, controlled area, inaccessible to other
animals, in which a person keeps, harbors or maintains five or more dogs under controlled conditions." A.R.S.
§ 11-1001(8).
An appointment will be scheduled for inspection of the kennel premises by an Animal Control Officer upon
receipt of this kennel permit application and fee. This kennel application properly executed and a copy of the
inspection report will then be foiwarded to, and must be approved by, the Maricopa County Board of
Supervisors. The kennel permit form will be sent to you after approval and will be valid for one year from the
date of the Board's approval.
NOTE: Failure to show for a scheduled inspection and/or failure of inspection will warrant a Subsequent
Inspection Return fee of $49 for each additional visit. Failure of inspection may result in denial of the kennel
permit and require individual licensing of each dog under the provisions of A.R.S. §11-1008.
PLEASE ANSWER THE FOLLOWING QUESTIONS AND INITIAL EACH RESPONSE
1. AI/VVe assume complete responsibility for the kennel at the premises for which I/we are making
applidation for a permit and understand that "kennel" means an enclosed, controlled area, inaccessible to other
animals, in which a person keeps, harbors or maintains five or more dogs under controlled conditions (ARS 11-
1001).
1/We certify that 1/We have dogs and that the kennel meets the definition in statute.
3. CT 1)We certify that 1/We have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals)
or 1 910.01 (dog fighting), or similar violations of any other state, county or municipal animal welfare law.
(Violations of license and leash laws DO NOT apply).
4. (A1A'INVe certify that all dogs over the age of three (3) months that are kept, harbored or maintained on the
preMises of the above named kennel have been properly vaccinated against rabies by a veterinarian licensed to

practice in the state of Arizona and that a current vaccination certificate signed by a licensed veterinarian is
maintained on the premises for each dog.
5.--2--"zr /We certify that I/We are submitting a valid copy of the rabies vaccination certificate for each
dog/with this application.
—iJ/We understand that a dog remaining within the kennel is not required to be licensed individually under
A. • § 11-1008. I/we also understand that a dog leaving the controlled kennel conditions shall be licensed
under A.R.S. § 11-1008 except if the dog is only being transported to another kennel which has a permit issued
under this section.
II/We understand that a person who fails to obtain a kennel permit under A.R.S.§11-1009 is subject to a
Itypf twenty-five dollars in addition to the annual fee.
8. ---1NVe understand that a person who knowingly fails to obtain a kennel permit within thirty days after
writtji notification from the county enforcement agent is guilty of a class 2 misdemeanor..
9. •.,411-he undersigned understand that that the kennel permit does not authorize the operation of any type
of ,siness and is solely used for the purpose of licensing multiple dogs.
INVe certify that all of the information I/We have provided is true and accurate under penalty of law.
Applicant Signature AkkatO Date:
IP
Applicant Signature Date:
For Official Use Only:
Copies of Valid Rabies Vaccination Certificates for each dog attached y es
Copy of Person's Valid identification Attached
Type of Identification submitted i\i/
BOS Approval Date Term of Permit

Maricopa County Animal Care & Control
KENNEL PERMIT INSPECTION
Date: September 17, 2016
Lt Timothy Rummel
Enforcement Division Lieutenant
2630 W. Rio Salado Parkway
Mesa, AZ 85201
(602) 506-6274
trummel@mail.maricopa.gov
Haraquahala Kennels / Kennel Permit # 2015-000018
Arthur McKay — Owner
10602 South 540th Avenue
Tonopah AZ 85354
Number of Dogs-14
• Are all dogs over the age of 3 months properly vaccinated for rabies and in possession of a valid rabies
vaccination certificate? ("Properly Vaccinated" means, by a licensed veterinarian or Maricopa County Animal
Care and Control)
M YES 0 NO
• Is the kennel an enclosed, controlled area, inaccessible to other animals, in which a person keeps, harbors or
maintains 5 or more dogs under controlled conditions?
11 YES ONO
• CORRECTIVE ACTION REQUIRED FOR COMPLIANCE - NONE
Lt Timothy Rummel

Maricopa County Animal Care and Control
25008. 27th Avenue
Phoenix, AZ 85009-6797
(602) 506-7387
http://pets.maricopagov
Receipt Number: R15-213534 Receipt Date: 09/17/2015
Person ID: P0610901
Phone: 928 3722262
HARQUAHALA KENNELS 9/17/2015 11:43:63AM
10602 S 540TH AVE
TONOPAH, AZ 85354
Item: Animal ID: Reference No: Price: Each: Amount:
KEN PERMIT A7777777 K16-000018 $328.00 1 $328.00
Total Fees Due: $328.00
Payments: Cash: $0.00
Check: $328.00
Credit Card: $0.00
Total Payments Received: $328.00
Thank Youl
Would you like to share your experience with our service to you? Change: $0.00
Please visit our website at hftp://pets.maricopa.gov and click on Balance Due: $0.00
"Contact Us" to email your comments for our review.
Animal Information:
A7777777 KENNEL PERM - BORN 9/14/1999, SPAYED, UNKNOWN/MIX, TRICOLOR DOG
License Information:
Tag Number: License Expires: Animat# Vacc Date: Vacc Expires:
Please retain this receipt with your pet's records
APODACAP EBUSOFF

Month DATE Other Cat Dog NO. PRINT Owner's Month ' Month DATE (Specify). Other Cat Dog SPECIES NO. PRINT Owner
VAC0410001 LI, Month LI (Specify) SPECIES: VAC0410001 •- VACCINATION 0 1, 's
VACCINATION • 0 El )0... m LAST -7,- . LAST Maths
Day 2y Day VACCINATED: u 1 ‘ Name Day Day dzi. VACCINATED: • &.
EX 2__ Male SEX: ,..S.f% , titlY _....,. & 1u2 EXPIRES: Altered Female Male SEX: uS50.2 REEr... a Addres
Lo EXPIRES: is Altered Female Address Year Year .t6
Year Year g.
3 1 , 3 1 E E LION , c 191A .
yr. yr. --$...,. 1'.4 E yr. yr. 3 FIRST
PRODUCER: 12 3 AGE: ITT PRODUCER: 12 Mo. AGE:
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or to RABIES E 12
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0 , CI _.., PRINT Serial ZASI-it ILO I=I ' -
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(Lot) izis104,19_ Over Under SIZE: CiTy„..e: ailvicls ball (Lot) 50 Under bail NASPHV
No. 50 20 point NASPHV No. Li 50 lbs. Ibs 20 - \ajo'nek's point
lbs. lbs. DAP pen " lbs. r011 pen
•k E or FORM . 0 or FORM
K I PR Mil. type 51 I -- NAME: 1._ y'l \UFO() type 51 CERTIFICATE
Address Signature Veterinari 1 NAME: CERTIFICATE AddreaP Signature Veterinarian's Veterinarian's REDOMINANT
Veterinarian's ilitpf DOMINANT MI .id42 vicsyx1 STATE MI6?
an STATE W. ':'',Y . # ‘902-
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License V, 523-E Phoenix, lizdian
Phr,',1 '..:.::•ff:' ‘ a._ No. I, Tag Tag 48 AZ iNo. Z1P ,--1-) Cert. Tag Tag
tlt, U COLORS: ZIB P -S-IZ j.cl__EPHONE Cert. #: fee A'1711 School z-,:-.1,UT'll COLOar.a be / TELEPHONE Serial #: fee
623-846-3979 AZ ?-, --- -TV Serial $: 85033 Rd 6 $:
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VAC0410001 Month Cf VA Month DATE. (Specify) Other Cat Dog SPEC], PRIN Owner's VAC0410001 Month A Month E DA (Specify) Other Cat Dog SPECIES: NC. PRIN Owner's
INATJION _ 0 0 W „.._., ES. VA 0 0 10 \\
VAGZI Name IN,PINIX1 Name
Day Day 's 06C & Day Day i ,,._M
EXPIRES: 1 1 TED: Altered Female Male SEX: 1T_RE * ATED; Altered Female Male SEX: &Address
Year Year Address Year ES: Year
yr. 3 yr 1 0 El WI1 "... . yr. 3 yr. 1 Ilt) 114 E _ '..C......) _
Lic. . PRODUCER: 12 3 AGE: ‘ix\irrA\o\_ PRODUCER: 3 AGE: .ck\riailc;\
Lic.Nacc. Mo. Mo. Ai Lic.Naco. Lic.NacZA Mo. Mo. +.
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Vacc. (First Mo. Vacc. (First Mo.
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Serial 'CP 0 - Serial <320 0 -
(Lot) L - 1.etters) Over 20 Under SIZE: r use VACCINATION (Lot) 51L4U-4C4 Letters) Over Under SIZE: use VACCINATION
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No. 50 lbs 20 point NASPHV No. 50 bs I 20 V.enrel point NASPHV
lbs.. Ins. 0 pen lbs. Ibs. pen
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A I=Ortrit ____,AL COLORS: it& #: fee 1.;ukotA _ COLORS: ..nEFrier #: fee
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RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name &Address PRINT - use ball point pen or type Cert. Serial II:
PRINT LAST FIRST MI TELEPHONE
IIPt r 4-1+W .14. Ci• Le/ —
NO. '''' STREET CITY STATE ZIP
Ole D .D.- S • 1 -4041.' AI,... ---It- n.i.) v. • PCZ--- .'5-5-1-ii
li
SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
Dog "in Male D 3 Mo. to 12 Mo. 113 Under 20 lbs. El -14(4-S r.--1:1 -6 1 ie.. 1 )-
Cat 0 Female -el 12 Mo. or older .2 20 - 50 lbs .....a .. .110.0, 0 k_ei
Other 0 Altered D Over 50 lbs. 0
(Specify) _.„...
DATE VACCINATED: PRODUCER: Veterinarian's # I I f
License No.
,;), 1 i-i o g'
Month Day Year (First 3 Letters) Veterinarian's • ,
1 yr. Lic.Nacc. 0 Signatur .----
VACCINATION EXPIRES:
a i i 1 3 yr. Lic.Nacc. 0 , Address I el
Month Day Year
Vacc. Serial (Lot) No.
VAC0410001
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
PRINT - use ball point pen or type Cert. Serial # :
Owner's Name &Address
PAW LAST FIRST j ,, MI TELEPHONE
• H-avettabot 'Int 1 q1S. Bia , 3.k.oa
NO. ST EET CITY ,.---- STATE
S—LiO Avt JOnyr4h - 1917Ss3s-L-i
1012 (-,0D S .
SPE ES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
Dog Male , 0 3 Mo. to 12 Mo. El Under 20 lbs. 0 ThAs k,y r blae.k.)
Cat 0 Female X12 Mo. or older 20 - 50 lbs D
Other 0 Altered 0 Over 50 lbs. NAME: br0Gt.k%
(Specify) GIAA /Wilk,
DATE VACCINATED: PRODUCER: Veterinarian's # )
License No.
1 2-9 t Li I
Month Day Year (First 3 Letters) Veterinarian's 0L, g
1 yr. Lic.Nacc. 1:1 Signature
VACCINATION E,S :
i n EXPIRn - yr. Lic.Nacc AddreaPA Y AND NEUTER CLINIC
7342W. Indian School Rd., Str.108
Month Day Year
Vacc. Serial (Lot) No. Phoenix, AZ 85033
623-R46-3070
VAC0410001

RABIES VACCINATION CERTIFICATE Tag fee $:
.. ADAPTED NASPHV FORM 51 Tag #:
PRINT - use ball point pen or type Cert. Serial #:
Owner's Name & Address
PRINTILAST FIRST MI ,...-, TELEPHONE
V\ a.vei vkain al 0, kR.inin )s (-in 372 2-2-u2
NO. STREET GAr __. STATE ZIP
10U0 -z S. S4(0 c 0 00-`pet I(-1 8S3 - L-1
SPECIX, SEX: AGE SIZE: PREDOMINANT BREED: COLORS:
Dog Male )<3 Mo. to 12 Mo. 0 Under 20 lbs. 0 h USle-f y 1/21 ack
Cat 0 Female 0 12 Mo. or older kK20 - 60 lbs
Other Ci Altered 0 Over 50 lbs. NAME:
(Specify) Bud:1\4 .
r --
DATE VACCINATED: PRODUCER: Veterinarian's # 1 1 ti/
License No.
Month Day Year (First 3 Letters) Veterinarian's ct, a
3 1 yr. Uc.Nacc.% Signature
VACCINATION EXPIRES: : 11-1ER COMC
--2._. 1 (., yr. Lic.Nacc. 0 I _..... Address ner;f: W. Indian 6cnool kW., Ste 10d
Month Day Year I ‘2---I S- L(O (14 Phoc:dx, M. 35933
Vacc. Serial (Lot) No. 823-848-3979
VAC0410001
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
PRINT - use half point pen or type Cert. Serial #:
Owner's Name & Addres
PRINT LAST FIRST MI 9 2% TELEPHONE -3-1 -z 2-2-kk 2_
K tin tn-{ 1 S
NO. STREE11 CITY ..--- STATE • ZIP
\ QUO 2_. S ' S LI 0 N-t. I 0 nocAln 2SS3S L-1
SPECIES: SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
Dog Male ') .,3 Mo. to 12 Mo. o Under 20 lbs. 0 k..., i 1 r
Cat 0 Female 0 12 Mo. or older 1K20 -50 lbs 0 I I# lik.r...k.f k
Other 0 Altered 0 Over 50 lbs. YQ, NAME:
(Specify) B} 0 rI d v
DATE VACCINATED: PRODUCER: Veterinarian's ' # IA s
License No. •
I--i 2— I S S 6 c
Month Day Year (First 3 Letters) Veterinarian's CL . g -
1 yr. Lic.Nacc. D Signature
VACCINATION ---z...._ EXPIRES: r6 3 yr. Lic.Nacc. ....., A Address spAy Amp I\JE1 lIFR CA NIC
ILL S- (AI Li 1-1- ' 7342 W. Indian School Rd., Ste 108
Moirj Day Year \jam. Serial (Lot) No. Phoenix, AZ 86033
623-846-3g79
VAC0410001

RABIES VACCINATION CERTIFICATE Tagfee $:
Tag #:
ADAPTED NASPHV FORM 51 Cert. Serial #:
PRINT - use ball point pen or type
Owner's Name & Address TELEPHONE
Cj 3.1 DaVa
PRIIYIT ar9Tutc,,,GIF (cA, e nnt I ml
CITY ST TE
NO o- • At -tp-or
d_-6 S-rnRE PREBIOMINANT BREED: COLORS:
SPECIES: SEX: AGE: SIZE:
Male 3 Mo. to 12 Mo. 0 Under 20 lbs. D 141A9eq 10Y-OW
Dog Female 12 Mo. or older 20 - 50 Ibs
Cat Over 50 lbs. NA NAME:
Other 0 Altered
[U1,17)1CeLd
(Specify)
DATE VACCINATED: PRODUCER: Veterinarian's # License No.
LI
Month Day Year (First 3 Letters) Veterinarian's e
1 yr. Lic.Nacc.
VACCINATION EXPIRES: W. Indian School Rd., Ste '108
3 yr. Lic.NacN y Addres7342 Phoenix, AZ 85033
) 4
623846319
Month - Day Year Vacc. Serial (Lot) No.
VAC0410001
RABIES VACCINATION CERTIFICATE Tag fee $:
ADAPTED NASPHV FORM 51 Tag #:
Owner's Name & Address PRINT - use ball point pen Or type Cert. Serial #:
PRINT LAffl FIRM- I - MI . TELEPHONE
aryitaha 1 a_ e_nne__ i caS 3T2- 221°2
NQ. STREET Ls-Li 0 Av y STATE ztS3c(
1 0 02. e —Forypot h
SPEC S. SEX: AGE: SIZE: PREDO INANT BREED: COLORS:
Dog Male y3 MO. to 12 Mo. 0 Under 20 ibs. O HAAS - • 10 letif.k.
Cat 0 Female 12 Mo. or older 20 - 50 lbs v1/41 (A y .
Other 0 Altered D Over 50 lbs. NAME: '
u....)h
(Specify) sc. f 1k--4-v ,
DATE VACCINATED: PRODUCER: Veterinarian's #
Li a OE License No.
7— 2-Z 1
Month Day Year 1 yr. Lic.Nacc. 0 "(First 3 Letters) Veterinarian's
Signature
VACCINATION EXPIRES:
.7.... r-zz ii 3 yr. Lic.Nacc Addnimormo
NETourR UTERd.CLINIC
Month Day Year 73,12 W. Indiairsci Ste
Veen. Serial (Lot) No, , 108
Phoenix, AZ 85033
- -846-3979

VACCINATION CERTIFICATE
JEM's Vaccination Clinic
OFFICIAL PROOF OF VACCINATION
Veterinary Services & Supplies
5373 S. Moson Road • Sierra Vista, AZ , SECTION 2.
- •
JEM's: 520-378-0057 • Clinic: 602-715-3544
TOITHE BEST OF MY KNOWLEDGE:
PET OWNER: FILL OUT SECTIONS 1-3. PLEASE PRINT CLEARLY. fl, My pet(s) are not pregnant.
Keep this record in a safe place. Duplicate requests are $10 each. Has had no recent occurrences of abnormal coughing, sniffing, vomiting and/or
/diarrhea.
SECTION 1: _ .0 Has no diagnosed allergy to vaccines or had a vaccine reaction in the past.
Oyvnpr's Name Jem's Feed Veterinary Services utilizet one of the finest vaccines available to the
'RN 6)/1 /141-LA tv ? veterinary profession. However, I also recognize the fact that a vaccine reaction is
Address possible yet rare. Should my pet become ill due to vaccination, I will not hold Jem's
,//}&'i) ?- Feed veterinarY Services responsible. I have read the inforrnation and give my consent
City /State /Zip 4 to Jem's Feed Veterinary Seniices to administer the injections listed belop.
'
Cell Phone a New Client 17 Existing Client Owner's -SignMure Date
Did you get a reminder card in the mail? 0 Yes 0 No
How did you hear about this clinic? 0 Flyer from Store 17 Mailer Promotion a Newspaper '0 Referral 11 TV o Radio o Website 0 Drive By 17 Other
SECTION 3:
PET 1 PET 2
17 Dog 0 Ferret a Male 0 Spay/Neut 0 Pregnant Iti Dog 0 Ferret 17 Male aSpay/Neut 0 Pregnant
a Cat a Other a Female 0 On Medication 11 Cat Other 0 Female 0 On Medication
Name: Age: Name: Age:
Breed: Color: Breed: : Color:
SECTION 4: VETERINARIAN USE ONLY
PET 1 PET 2
Rabies Type: PRICE NEXT BOOSTERS Rabies Type: • I. -.' , ., _ PRICE NEXT BOOSTERS
Lot # mfg. ' I I I ponoce:gifotoinocsiuedrse. 3.4 6 12 38 1 r.,f ii Mfg. k rice Does of not boosters. include Weeks 34 Months 6 Months 12 Months 36
, _, t Weeks !faiths /Soollis Months -"'"' "
Rabies Date Vaccinated: / / Rabies Date Vaccinated: / / ' - -.,
Rabies Vaccination Due: / l ,• Rabies Vaccination Due: / I
DA2PPv / DA2PPv+L / Corona DA2PPv 1 DA2PPv+L / Corona
Bordetella - Nasal! Injectable Bordetella - Nasal! Injectable
Lyme / Giardia / Rattle Snake Lyme / Giardia I Rattle Snake
Deworming (Prole! 50 mg/m1) CC Deworming (Protal 50 mg/ml) CC
Cat 4-in-1 (FVRCP) / Leukemia /FIP Cat 4-in-1 (FVRCP) / Leukemia /FIP
Heartworm / SDX / 4DX Test! OPos ONeg Heartworm / SDX / 4DX Test / 0Pos ONeg
Rx Heartworm: Rx Heartworm:
Feline Leukemia / FIV Test OPos ONeg Feline Leukemia / FIV Test OPos ONeg
Parvo / Giardia Test OPos ONeg Parvo / Giardia Test 0 Pas ONeg
Flea! Tick Control: Flea! Tick Control: ,
Micro Chip Mfg. # Micro Chip Mfg. #
Other: Qty. .,;_ Other: Qty.
Other: Qty. Other: Qty.
Other: Qty. . Other: Qty.
Other: Qty. Other: Qty.
NOTES! DOSAGE Boosters im3weekstAnnually — NOTES! DOSAGE Boosters in . 3 weekstAnnually
lei,
, 1 ,d-- .:',: , •.,
• 'i - ' ,,
. • HR: i Resp: , , ..,\ HR: \ . ' Respi
Temp: ' Weight . Temp: i Weight
PHYSICAL EXAM : ' PHYSICAL EXAM
i , Checked Unable in Check 1 , Checked Unable is Check
Gen. App. `iti o Gen. App. p 0
Skin 6 in Skin 9 a
Eyes 17.1 a Eyes li 0
Ears d, Cl Ears Cl 0
Mouth Cl Cl Mouth O 0
HEALTH WITHIN NORMAIL LIMITS ' HEALTH WITHIN NORMAIL LIMITS
I r;- -,, , , ;0 Yes 0 No )7Xes 0 No
. .
Veterinarian: ' Location: Tech. Initiat•
State Lic #: Payment: Code: TOTAL:
omen= •rozeimanwswoun

VACCINATION CERTIFICATE
JEM's Vaccination Clinic
OFFICIAL PROOF OF VACCINATION
Veterinary Services & Supplies
5373 S. Moson Road • Sierra Vista, AZ 1 SECTION 2:
JEM's: 520-378-0057 • Clinic: 602-715-3544
TO THE BEST OF MY KNOWLEDGE:
PET OWNER: FILL OUT SECTIONS 1-3. PLEASE PRINT CLEARLY. 0 My'pet(s) are not pregnant
Keep this record in a safe place. Duplicate requests are $10 each. 0 Has had no recent occurrences of abnormal coughing, sniffing, vomiting and/or
diarrhea.
SECTION : 0, Has no diagnosed allergy to vaccines or had a vaccine reaction in the past,
Owner's Name Date Jam's Feed Veterinary Services utilizes one of the finest vaccines available to the
veterinary profession. However, I also recognize the fact that a vaccine reaction is
Address possible yet rare. Should my pet become ill due to vaccination, I will not hold Jem's
Feed veterinary Services responsible. I have read the information and give my consent
City /State /Zip
to Jam's Feed Veterinary Services to administer the injections listed below.
Cell Phone
0 New Client 0 Existing Client Owner's Signature Dale
Did you get a reminder card in the mail? 0 Yes 0 No
How did you hear about this clinic? 0 Flyer from Store 0 Mailer Promotion 0 Newspaper 0 Referral 0 TV 0 Radio 0 Website 0 Drive By 0 Other
I SECTION 3:
PET 1 PET 2
CI Dog 0 Ferret 0, Male o Spay/Neut 0 Pregnant 0 Dog 0 Ferret 0 Male 0 Spay/Neut 0 Pregnant
0 Cat o Other 0 Female 0 On Medication 0 Cat 0 Other CI Female 0 On Medication
Name: Age: Name: Age:
Breed: Color: Breed: Color:
F—SECTION 4: VETERINARIAN USE ONLY
PET 1 PET 2 •
Rabies Type: PRICE NEXT BOOSTERS Rabies Type: PRICE NEXT BOOSTERS
Lot # Mfg. price Does of not boosters, Include Weeks 3.4 Months 6 Months 12 Months 36 Lot # Mfg. I I • Does nce of not boosters. include Weeks 3-4 Months 6 Months 12 Months 36
Rabies Date Vaccinated: / / Rabies Date Vaccinated: / /
Rabies Vaccination Due: / / Rabies Vaccination Due: / /
DA2PPv / DA2PPv+L / Corona DA2PPv / DA2PPv+L / Corona
Bordetella - Nasal / Injectable Bordetetla - Nasal / Injectable
Lyme / Giardia / Rattle Snake Lyme / Giardia / Rattle Snake
Deworming (Protal 50 mg/ml) CC Deworming (Protal 50 mg/ml) cc
Cat 4-in-1 (FVRCP) / Leukemia /FIP Cat 4-in-1 (FVRCP) / Leukemia /FIP
Heartworrn / SDX /4DX Test / OPos ONeg Heartworm / SDX / 4DX Test / 0 Pos ONeg
Rx Heartworm: Rx Heartworm:
Feline Leukemia / FIV Test OPos 0 Neg Feline Leukemia / FIV Test • OPos ONeg
Parvo / Giardia Test 0 Poe 0Neg Parvo / Giardia Test CI Fos Cl Neg
Flea / Tick Control: Flea / Tick Control:
Micro Chip Mfg. # Micro Chip Mfg. #
Other: Qty. Other: Qty.
Other: Qty. Other: Qty.
Other: Qty. Other: Qty.
Other: Qty. Other: Qty.
NOTES / DOSAGE Boosters in 3 weeks! Annually NOTES / DOSAGE - Boosters in 3 weeks/ Annually
HR: Resp: HR: Resp:
Temp: Weight: Temp: Weight:
PHYSICAL EXAM PHYSICAL EXAM
Checked Unable to Check Checked Unable In Check
Gen. App. 0 o Gen. App. 0 0
Skin in in Skin o 0
Eyes a in Eyes 0 0
Ears 0 o Ears 0 0
Mouth 0 0 Mouth in in
HEALTH WITHIN NORMAIL LIMITS HEALTH WITHIN NORMAIL LIMITS
0 Yes 0 No 0 Yes 0 No
Veterinarian: Location: Tech, Initial:
State Lic #: Date: Payment: Exp.: Code: TOTAL:
I