Extracted text (via pymupdf_layout)
28887 characters
Maricopa County
Animal Care And Control
2500 South 27 th Avenue
Phoenix, AZ 85009
(602) 506-7387 Tele.
(602) 506-2739 Fax
KENNEL PERMIT APPLICATION
New 0 Renewal Permit # 15-053
Name: CIUDO 7od \VOR-tvlY-Airc ennel Name: S\J\)
Mailing Address: LPt—i-O E N in ae Kennel Location: (Y,SciI A-2_ 6; tie 'SE/Veza-te„
City inCVAI , AZ ZIP County Supervisorial District
Home Phone: 6+CCO S-1-0 10 OM- —1 Kennel Phone: L-p sloe' oos --7
(902_ Lurss
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 'operating a kennel" must obtain a permit issued
by the Board of Supervisors where the kennel is located except if each individual dog is licensed. A.R.S. § 11-
1009 and MC Ordinance No. 13, Sec. 4. define a "kennel" 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 forwarded 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 require individual licensing of each dog under the provisions of ARS
11-1008.
PLEASE ANSWER THE FOLLOWING QUESTIONS
Initial Each
14
e assume complete responsibility for the kennel at the premises for which I/we are making
api (.,,fon 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 1)0001).
/We certify that the kennel has been approved by the local zoning authority (if applicable) at the
prenfttis for which I/we are making application for a permit.
35=g di /We certify that INVe have dogs and that the kennel meets the definition in statute.
t /We certify that INVe have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals)
or 13- 10.01 (dog fighting), or any other state, county or municipal animal welfare law. (Violations of license
and leash laws DO NOT apply.)
5.1horibtiNVe certify that all dogs over the age of three (3) months that are kept, harbored or maintained on the
premi&i 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.
NVe understand that a dog remaining within the kennel is not required to be licensed individually under
ART1V-1008. l/we also understand that a dog leaving the controlled kennel conditions shall be licensed under
ARS 11-1008 except if the dog is only being transported to another kennel which has a permit issued under this
• section.
d- tie INVe understand that a person who fails to obtain a kennel permit under ARS 11-1009 is subject to a
pen.; Tof twenty-five dollars in addition to the annual fee.
/We certify that INVe are submitting a valid copy of the rabies vaccination certificate for each
, his application.(1- Ln"-(*e-Ac U- tUA".7tAr1/4 ter 1_9 vI-t- - .3 eregnoNici-1 0.04 %,%8+
/We understand that a person who knowingly fails to obtain a kennel permit within thirty days after writtent:I=
notifik54ton from the county enforcement agent is guilty of a class 2 misdemeanor,
Is this kennel permit being obtained for the purposes of operating a busirtr including but not limited to
breede groomers or boarding establishments? (Please check one) YES ONO
If the answer is "YES", you will need to provide proof of lawful presence in the United States in order to obtain a
kennel permit for the purposes of operating a business. The forms of identification accepted for this purpose
are listed below.
A.R.S. § 41-1080(A) provides:
After September 30, 2008, an agency or political subdivision of this state shall not issue a license to an
individual if the individual does not present any of the following documents to the agency or political
subdivision indicating that the individual's presence in the United States is authorized under federal law:
1. An Arizona driver license issued after 1996 or an Arizona non-operating identification
license.
2. A driver license issued by a state that verifies lawful presence in the United States.
3. A birth certificate or delayed birth certificate issued in any state, territory or
possession of the United States,
4. A United State certificate of birth abroad.
5. A United States passport.
6. A foreign passport with a United States visa.
7. An i-94 form with a photograph.
8. A United States citizenship and immigration services employment authorization
document or refugee travel document.
9. A United States certificate of naturalization.
10. A United States certificate of citizenship.
11. A tribal certificate of Indian blood.
12. A tribal or bureau of Indian affairs affidavit of birth.
Please submit a photocopy of both the front and back of your identification with your completed
application. Please also be prepared to present your identification at the time of inspection by the field
services officer.
If the answer to question 10. above is "NO" please answer question 11.
11. 1/We certify that the kennel permit is being used solely for the purpose of licensing my own multiple
companion dogs in my household.
JAW certify that all of tAinformation 11We hayp providdd is true and accurate tinder penalty of law.
Applicant Signature Date: L-4
Applicant Signature Date: 1--1-
For Official Use Only:
Copies of Valid Rabies Vaccination Certificates for each dog attached
Copy of Person's Valid Identification Attached Type of Identification submitted
BOS Approval Date Term of Permit
Maricopa County
Animal Care & Control
2500 South 271 Avenue
Phoenix, AZ 85009
Phone: (602) 506-7387
pets.maricopa.gov
KENNEL PERMIT PREMISE INSPECTION
APPLICANT _\0. te-NZthel ov,d (As. ktse reGt
STREET ADDRESS 4 N ono
CITY, STATE, ZIP i'Aescf
HOME PHONE 4g..)-5b0 • (X)S-7 BUSINESS PHONE b(:). 1-tee° 5-3tr3
a
COUNTY DISTRICT KENNEL LICENSE # JS 053 NUMBER OF DOGS 1
1. Are all dogs over the age of three months properly vaccinated for rabies and in possession of a
valid rabies vaccination certificate?
Yes No
2. Is the kennel an enclosed, controlled area, inaccessible to other animals, in which a person
keeps, harbors or maintains five or more dogs under controlled conditions?
Yes No
CORRECTIVE ACTION NEEDED FOR COMPLIANCE AND DAYS GIVEN
BEFORE REINSPECTION. (Note: There will be $49 re-inspect fee payable to the Inspector by
check upon each return visit.)
Deputy Enforcement Agent Date
Maricopa County Animal Care and Control
2500 S. 27th Avenue
Phoenix, AZ 85009-6797
(602) 506-7387
http://pets.maricopa.gov
Receipt Number: R14-078681 Receipt Date: 04/1712014
Person ID: P2249978
Phone: 480 5600057
SWBSIKWITIT KENNELS 4/17/2014 11:32:40AM
6403 E NANCE ST
MESA, AZ 85215
Item: Animal ID: Reference No: Price: Each: Amount:
KEN PERMIT A0000000 K15-000053 $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 http://pets.maricopa.gov and click on Balance Due: $0.00
"Contact Us" to email your comments for our review.
Animal Information:
A0000000 NO NAME - BORN 3/18/2004, SPAYED, PIT BULL/PIT BULL, TAN AND WHITE DOG
License Information:
Tag Number: License Expires: Animal# Vacc Date: Vacc Expires:
Please retain this receipt with your pet's records
shawcrof EBUSOFF
CaringHeart VACCINATION CERTIFICATE
I 0 4 0 13
Official Proof of Vaccination
Veterinary Services Keep this record in a safe place. Duplicate requests $10. Corporate Office Hours:
Mon - Fri 9:00 am - 5:00 pm
480-699-9950 P.O. Box 7479 Mesa, AZ 85216
PET OWNER: Fill out sections #1-3 OFFICIAL RECORD - PLEASE PRINT CLEARLY www.caringheartsvetservice.com
Last Name: [WV MUM First Name: 11111111111M1 I I I I LII
Address: Jkir zirr Icl E-1(7 i_ILL EMU
1-111E1-11-1_1__
City: _ 111111I E I I State: r , ()I _ 11 2. I Zip:
Email: V- < -' ',,, ,==") LE e d = MDLEMI mr
t
Home: Cell: ( ) 2-, Work: (4-f kt-.) - 061 ( (y)
Hhowledge having read and I understand the back of this document. Being aware
TT' se facts, I give my permission to CARING HEARTS VETERINARY SERVICES x
II and/or the Doctor to treat and/or administer the vaccinations listed below. DATE 2, / / (4-1
..1111ni Client n Existing Ghent Did you get a reminder card in the mail? 7) Yes C) No There is a $1-$3 waste disposal fee per animal. Prescription ONLY fee $10.
0 How did you hear about this clinic? \O"Flyer from Store El Promotional Mailer El Newspaper ci Referral EI TV CI Radio ci Website o Drive By [I Other
Dog El Ferret ,E[Male El Spay/Neut ri Pregnant )0 Dog 71 Ferret El Male El Spay/Neut I] Pregnant
tj Cat (71 Other CI Female CI On Medication d Cat El Other lel-Female On Medication
-
Name: ).) Age: ci Wks Nam( Age: C1 Wks
Breed: 001I17 GA KA t. t. Mos Breed: CI Mos
Colors: srm.I Cr; CI 1 Yrs Colors: gt Isf-2-,v -C Yrs
R. - OFFICE USE ONLY - PLASE- DO,NAT-:-WRITE3,BELOW
Rabies Type; KILLED VIRUS Mfg. _{-- v___. PRICE NEXT BOOSTERS Rabies Type; KILLED VIRUS Mfg. [ _II 7- PRICE NEXT BOOSTERS'
Lot Ir-- .7)C1 q (5 cl k- I 17.) Tag ' (Does not include 34 6 12 36 Lot #5 -)) ,,,:•2 eri oq cf y'..> ra d ' (Does not Wilde 14 6 12 36
Rabies Date Vaccinated: ---) _-...) J3_4 FiX•Estged,,hals.$) -/- ..1.4 price of boosters.) Weeks Months Months Months ..,._., jr4t ,tws.,4,,,, ,, tutt1 Price oi boosters) Weeks Months Months Months
s.1 Rabies Date Vaccinated:, -- , :.13. • 1- -,) , 4-1-4144 -,, ,.„, ,.., A
Rabies Vaccinatizn-D-Ue: "") Kr.) / I C., $ " C / Rabies Vaccinatioter15 -ue: ..") / "c; t/ / ,r.. ) $ .1 `), 1 I
DA2PPv / DA2PPv+L / Corona $ DA2PPv / DA2PPv+L / Corona ' $ .
Bordetella - Nasal / Injectable $ Bordetella - Nasal / Injectable $
Lyme / Rattle Snake $ Lyme / Rattle Snake 1
Deworming (Protal 50 mg/ml) cc $ Deworming (Protal 50 mg/ml) cc $
Cat 4-in-1 (FVRCP) / Leukemia $ Cat 4-in-1 (FVRCP) / Leukemia $
Heartworm / 3DX / 4DX Test (1 Pos 71 Neg $ Heartworm / 3DX / 4DX Test 0 Pos CI Neg $
FELV / Fl V / Parvo/ Giardia Test CIPos GI Neg $ FELV / FIV/ Parvo 1 Giardia Test CI Pos 171Neg $
Rx Heartworm Mfg: Rx Heartworm Mfg:
Pets Weight: Cl 0-25# 1:1 26-50# 7151-100# $ Pets Weight: ID 0-25# 0 26-50# CI 51-100# $
Flea / Tick Control: $ Flea / Tick Control: $ Pi
Micro Chip Mfg. $ Micro Chip Mfg. $ 7 i
Micro Chip # Micro Chip #
Other: $ Other: $
Other: $ Other: $
Other: $ Qty: @ $ Other: $ Qty: @ $
Other: $ Qty: .$ Other: $ Qty:
Treatment Fee: $ Script Fee: $10 $ Treatment Fee: $ Script Fee: $10 $
t Exam FeeV $20 Health Certificate: $25 $5 1 00 / Exam Fee:($5)$20 Health Certificate: $25 $:- ,, or,
t: Waste Disposal Fee: 41 $2 $3 $ N . n (.1 "‘') Waste Distiers-al Fee: ($1 $2 $3 $
HR: /Zi t_ .:1 Resp: (A) NEXT BOOSTER DUE ON: ---) _) En , f___ HR: is,P._2_ Resp: ,431.4.k.f -
t - ) i ,-, NEXT BOOSTER DUE ON: "--) / .-)C ( C)
Temp: I r': It 1 Weight: ill , z..-, _ NOTES/DOSAGE Temp: 1 flit . Weight: .Stt.-..'
NOTES/DOSAGE
PHYSICAL EXAM: PHYSICAL EXAM:
Gen. App. Checked ril Unato'e CI to Check Checked Unah'e to Check
Gen:App. rp 171
Skin CI a Skin Lii 17
Eyes EII CI Eyes lii Cl
Ears [LI IP El . Ears ITLJ 171 A) A' (.._.
Mouth CI //,/ /1.," C...-, Mouth 71 -
iti
HEALTH WITHIN NORMAL LIMITS HEALTH WITH! NORMAL LIMITS
Yes tl No El Yes 03.,, No . CI
Veterinaria44Q 4.2..4A,v44-00 Location: ( L). _ Tech. bit: 4 . (4 Fee: $
State Lic #3616 Date: -2- $ Bal $ CaShp J CC Vi 171 CVC Cashier I nit: TOTAL: $ 1 cl t tj
White: CARING HEARTS VETERINARY SERVICES LLC Yellow: CLIENT/COUNTY
CaringHeart VACCINATION CERTIFICATE
Official Proof of Vaccination 044 6
Veterinary Services LLC Keep this record in a safe place. Duplicate re q uests $10. Corporate Office'HottEs:
Mon - Fri 9:00 am - 5:00 pm
PET OWNER: Fill out sections #1-3 480-699-9950 P.O. Box 7479 • Mesa, AZ 85216
OFFICIAL RECORD - PLEASE PRINT CLEARLY www.caringheartsvetservice.com
Last Name: loJ I I 1 1 I I r
mem• First Name:
Address: inglIMENIri -_, VI
City: Pil-fl 101 I F u ll I I I H I ll I 11 1 1 IIIIIIIII1 , a
1 State:MU Zip: '6- E II 6
Email: 0\ 6 • ' i 1 01 I ) •
lk
Home: (4( •?. C Vz< - .;---)-) r,' ) Cell: ( i' ( ' 2 ) ' - k c51( - -, 2)3 - 2-- Work: ( _
I acknowledge having read and I understand the back of this document. Bein g aware )
of these facts, I g ive my permission to CARING HEARTS VETERINARY SERVICES
LLC and/or the Doctor to treat and/or administer the vaccinations listed below. A X A,,\,,,,, y_,,,,,,A___ DATE - .- /Z-Li- i
) i (
0 New Client El Existing Client Did you get a reminder card in the mail? 71 Yes [1 No There is a $1-$3 wastr, e disposal fee per animal. Prescription ,
ONLY fee $10.
2 How did you hear about this clinic? o Flyer from Store Cl Promotional Mailer o Newspaper o Referral ow El o
Radio 71Website Drive By (Other
PET #1
rin PET 112
og in Ferret El Male El-Spy/Nutt --- Trzant ] Dog 7) Ferret 0 Male
El Ca --TIM% . female n On Medication n Cat • nSpay/Neut-- 77 pregnant
3 Othep-7,-. emale 71 On Medication I '
Age: Cl Wks Name: L-) Age: [I Wks
Breed: • C A -\ 1-2-,1 i ( - El m os Breed: 1117. 1 I CO\ 1, 1-\ 1 V-2.4 1 ( i 1 r El mo
Colors: \ H( . Z_ yrs Colors: -t--<
lNa1k
FOR OFFICE USE ONLY - PLEASE DO NOT WRITE BELOW THIS LINE ,t
Rabies Type; KHD1 yrus Mfg, rff::, in12:1 PRICE NEXT BOOSTERS Rabies T •e. LI_E:0 • si:
Lot#5 001 nOt include 3,4 6 12 36 Lot # • ' • Rrfil PRICE NEXT BOOSTERS
Rabies Date Vaccinated: .v•I • OW or bOosters.) Weeks Months Months Monlhs ) --- Tag # rt-tr, eke (Does not tnekide 3,4 6 52 36
Rabies Date Vaccinated: or boOSW I Weeks Months Months Months
Rabies Vaccination Du 5 1,;94 / j 7 $rAcl f 'Rabies Vaccina• tion ell (,
11?_).
DA2PPv / DA2PPv+L7COMTVa $ DA2PPv / DA2PPv+L/ Corona 1 •
Bordetella - Nasal / Injectable $ Bordetella - Nasal / Injectable
Lyme I Rattle Snake $ $
Deworming (Protal 50 mg/m1) cc Lyme / Rattle Snake $
Cat 4-in-1 (FVRCP) / Leukemia a$ Dewormin g (Pieta' 50 m g/ml) cc $
$ Cat 4-in-1 FVRCP / Leukemia $
Heartworrn I 3DX / 4DX Test CI Pos II Neg $ ' Heartworm / 3DX / 4DX Test CI Pos CI Neg $
FELV 1 FIV I Parvo / Giardia Test 1 Pos CI We' $
Rx Heartworm Mfg : ' •
Pet 's Weight: El 0-254 D 26-5040 51-100# $ Rx Heartworm n Mfg :
Flea / Tick Control: Pet's Wei ght: 0-25# n 26-50# El 51-100# $
Micro Chip Mfg. $ $ 7 1 Flea / Tick Control: $ I INI
Micro Chip /I Micro Chip Mfg . $ 7
Micro Chip if
Othe : $
Other: Other: $ r
$ [ Other: $ r i I
Other: $ Qty : @ $ Other:
Other: $ -Qty: 0 $ Other: $ Qty: @ $
Treatment Fee: $ Script Fee: $10 $ $ Qty : e $
Exam Fe 15 $20 Health Certificate: $25 $ - CO Treatment Fee: $ Script Fee: $10 $
Waste Disposal Fee: ' Exam Fee $5 $20 Health Certificate: $25 $ Or'
4, $2 $3 $ I a. - --; Waste Dis•osal Fee: $1 12 $3 $ i . 4
HR: Resp: j. NEXT BOOSTER Diu KV:- S 1 c2 t 1 I HR: tad, Resp:
Temp: Weight: 148 ., III NEXT BOOSTER GE ON: f ,-9q 1 rf-
slit2_TES , / DOSAGE______------ _ _ Temp -- . • i dole. - . NOTESIDOSAGE
PHYS CI‘ CAL ed EXAM: UnatiFrea ifalifIRMIMg PHYSICAL EXAM: i .poriiiiiiiiiwypow I
Gen. App. A AL c unab416ch44
Skin o Get. App.
Eyes o Skin 0 -9-IrMlirrir
Ears n Eyes 0 g.
Mouth Ears m ' PLAPRiMONC, ,
Ci CI Mouth
HEALTH WITHIN ORMAL LIMITS 0 ill .
Yescg No Cil HEALTH WITHIN NORMAL LIMITS
--') 1 Yes 15(,„ No 0
Veterinarian: a*Akg V/YIb Location: -
Tech. Int Fee: $ g
State tic # Lic.#36169te:C, 9( 1 Pd S Bal $ C0144. .6ek") 98
Cashier Mit: TOTAL: $
Wh le: CARING HEARTS VETERINARY SERVICES LLC : CLIENT/COUNTY
Date of Rabies Vaccination: 12-06-13
Next Rabies Vaccination On: 12-06-14
VETERINARY CLINIC OWNER OF ANIMAL
Alta Mesa Animal Hospital Ashley Keyes
6704 East Brown Rd. 6403 E. Nance St
Mesa, AZ 85205 Mesa, AZ 85215
480-981-1244
This is to certify...
THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
Patient information...
PATIE T: Roxie TAG NO:
SPECIES: Canine WEIGHT: 40.80
SEX: Female AGE: 12M
Color and markings: Red Breed: English Bulldog
sIN
Signed
Jill Patt, DVM License: 3768
Rabies Vaccine Information...
MFG BY: PFIZE SER.NO: S287243B
LOT EXP: 1APR14
Other Vaccine Information:
06-06-14 C127 Office Visit - Health Review
12-06-14 L152 Heartworm & Tick Disease Test
05-07-13 S265 OVH (Spay) - Canine
12-06-14 V199 Rabies - Canine - 3 Year
CaringHeart VACCINATION CERTIFICATE
Official Proof of Vaccination
Veterinary Services LLC Keep this record in a safe place. Duplicate requests $10. Corporate Office Hours:
Mon - Fri 9:00 am - 5:00 pm
480-699-9950 P.O. Box 7479 • Mesa, AZ 85216
PET OWNER: Fill out sections #1-3 OFFICIAL RECORD - PLEASE PRINT CLEARLY www.caringheartsvetservice,com
Last Name: E •, (,, , (-- (> 1I _i I u First Name: A A
Address: INIMFA 41 r RIPM&Ellcl 1-- I I 1 _IL _OE i
City: ' e IILIiI1I 1LIIIIIJI [111111 II I I State: EIR. Zip:1:I :-• OICL
1 Email: -',/i f ' -.' 4 1 ‘,A, 1111 ' ''l ILE ,---i nr-TEEL -1-1-1
Home: ( ) - 1 Cell: 0/C 1i -- k (', - c:1, 72-_-_. :2_2> Work: ( i.-1- () ) (- .-.--ii-i- - 6c1 co L.,
I acknowledge having read and I understand the back of this document. Being aware
of these facts, I give my permission to CARING HEARTS VETERINARY SERVICES A A '. -4-i^‘ 1 %Li it--c_}-,:_-,-- /.4 -79, N
LLC and/or the Doctor to treat and/or administer the vaccinations listed below. . ( DATE -7-,
New Client 0 Existing Client Did you get a reminder card in the mail? 0 Yes D No There is a $1-$3 waste disposal fee per animal. Prescription ONLY fee $10.
2 How did you hear about this clinic?1:iil,Flyer from Store p Promotional Mailer ci Newspaper ci Referral EI TV El Radio El Website n Drive By p Other
PET #1 PET#2
; -Dog CI Ferret .rj:Male Spay/Neu? CI Pregnant .rj Dog ll Ferret O Male -Spay/Neut.-- -_ 0 Pregnant
O Cat 71 Other - 0 Female 0 On Medication II`Cat 11 Other . -0 Female il On Medication _
3 Name: ,----; --'\ I- v Age: a Wks Name: c ,--r-' ir^ii.) r_ \ ti,_. r,-,1 ,., i --( \ 6,:\..\-J v" '-'s )-e , A . Li Wks /Lk!
Breed: C ,. ‘r-,„ ‘T`= = \ \r"-\ ' ' \.__.16,', i'Vji._• .; f m 171 os Breed: Ariir\-t i''. 1 c:-.--1.- V ) 6 ti- L.,- .,, mos
Colors: i,-.0. ‘ 0 ,i(- yrs Colors: ,k--.:1.t. t._,`-..i SiTh a Yrs
FOR OPPICE-1:1SE0 - I/-- =_P A5E7DO3NOT4WRITagrOVV7rtlIS LiNE
Rabies Type: KILLED VIRUS Mfg. st--‘:- -i_r__-- PRICE NEXT BOOSTERS Rabies Type: KILLED VIRUS Mfg. Ur=1 PRICE NEXT BOOSTERS
Lot #', '.- 0 q (--, q (t) Tag, (Does not include 3-4 IN 12 36 Lot # j 3q a (-.1 q I) Tayt (Does nol include 3.4 6 12 36
(iRe...w.ig,...ieri.ei Pim of boosters.) Weeks • Months MonIhs iiir,,,,,.Qi,,egieeui price Of [lingers.) Weeks Months Months Months
Rabies Date Vaccinated: 4-1 . / - 3-1 i i Li Rabies Date Vaccinated: 7) / :::„) 6(k / 11
Rabies Vaccination C(.1e: -I-) / '`-1 ill / I 1 VI) ,rici ?----- Rabies Vaccration Due: 'll) / f.."2- ' /,_1_._1: $ ; C) , (I. . ig .
DA2PPv / DA2PPv+L / Corona $ DA2PPv / DA2PPv+L / Corona $ •
Bordetella - Nasal / Injectable $ Bordetella - Nasal / Injectable $
,.. Lyme / Rattle Snake $ Lyme / Rattle Snake $
Deworminq (Protal 50 mg/ml) cc $ Deworming (Prole' 50 mg/m1) cc $
Cat 4 -in-1 (FVRCP) / Leukemia $ Cat 4 -in -1 (FVRCP) / Leukemia $
Heartworm / 3DX / 40X Test El Pos 0 Neg $ . Heartworm / 3DX / 4DX Test n Pos 171 Neg $
FELV/FIV/ Parvo / Giardia Test 0 Pos El Neg $ • FELV/F IV / Parvo I Giardia Test o Pos 173 Neg $
Rx Heartworm Mfg: Rx Heartworm Mfg:
Pees Weight: 0 0-25# CI 26-50# 0 51-100# $ Pees Weight: 0 0-25# O 26-50# 0 51-100# $
Flea / Tick Control: $ Flea / Tick Control: $
Micro Chip Mfg. $ Micro Chip Mfg. _$
Micro Chip # Micro Chip # ,
Other: $ Other: $
Other: $ I Other: $ . -I
Other: $ (Hy: @ $ Other: $ Qty: @ $
Other: $ Qty: Other: ' $ Qty: e $
Treatment Fee: $ Script Fee: $10 $ Treatment Fee: $ Script Fee: $10 $
f- Exam Fee:46120 Health Certificate: $25 $5 . a 0 . Exam Fee:p$20 ,H,9alth Certificate: $25 $1.2 „(1)(L
Waste DispOSal Fee: $i 1 $2 $3 1$ 1., .A1) Waste Disposal Fee: ('$1) $2 $3 $ 1 , ii //
HR: A c-:' Rasp: NEXT BOOSTER DUE ON: 2 S 1 (c . . HR: /3 L Resp: ..e5 NEXT BOOSTER DUE ON: ir /XI
Temp: / 0 ( (7; Weight: (-(. .g---- NOTES / DOSAGE Temp: 1103. 6 Weight: .., NOTES / DOSAGE
PHYSICAL EXAM: PHYSICAL EXAM:
Checked UsaYs to Check Gen. App. Checked co Unalkk, El to Check
Gen. App. 113 CI
Skin Ci CI e,,:7A..2<_.- " Skin 11 n _
Eyes Q o Eyes ...------ _._
Ears ED Ears C
Mouth 1 o Mouth n
HEALTH WITHIN NORMAL LIMITS HEALTH WITHIN NORMAL LIMITS
Yes ri No I=1 .-r. Yes El No EI .
Veterinarian:TaajlailiVA*Irflthir Location: ktutt.h• Tech. (nit: H (!y" Fee: $
State Lic # 3616 Date: 'y 1 , t- I Pd $ Bal $ CC cvc — Cashier hit: t\V-1 1 TOTAL: $ (OA/
White: CARING HEARTS VETERINARY SERVICE Yellow: CLIENT / COUNTY
e-t-t-trat7,7=1 .._Ss
CaringHeart VACCINATION CERTIFICATE
0E1 001
Official Proof of Vaccination
Veterinary Services LLC Keep this record in a safe place. Duplicate requests $10. Corporate Office Hours:
Mon - Fri 9:00 am - 5:00 pm
480-699-9950 P.O. Box 7479•Mesa, AZ 85216
SITITO OFFICIAL RECORD - PLEASE PRINT CLEARLY www.caringheartsvetservice.com
Last Name: HEIN En I First Name: 111111111EMIIII ii LE arliM
Address: lc I I I= ELIE OE- mu
City: MCITIMP IL _JLLE _LEE I I State: Zip: FE 21471
11 111111 g. CID urnu I DEIEMILJL
Cell: ((- )4--fkk 2, Work: ( C-1 SO ) s-J - ()C-71
;knowledge having read and I understand the back of this document. Being aware
hese facts, I give my permission to CARING HEARTS VETERINARY SERVICES
and/or the Doctor to treat and/or administer the vaccinations listed below. A j-'s f DATE /
:-31:1tiew Client J Existing Client Did you get a reminder card in the mail? [I Yes 17i No There is a $1-$3 Wdste disposal fee per animal. Prescription ONLY fee $10.
0 How did you hear about this clinic? r Flyer from Store 71 Promotional Mailer El Newspaper El Referral EJ TV O Radio I] Website 6 Drive By El Other
l'Dog CI Ferret .17)1v1ale aSpayiNeut-- ['Pregnant 71 Dog Cl Ferret ID Male -7J-Sprayffle-OF 1 Pregnant
"El Cat 0,Other d Female 30n Medication Cat ID Other 57J-Female --g On Medication
Name: k .>< El Wks Na \C\ S \I-Y) ,\ia l Age: El Wks
Breed: r. • XMos Breed: n Mos
Colors: - 1) 0 Yrs Colors: Ilsa Yrs
OW-OFFICE-USE _ _ _ ONLY _ -orP EASEDO .= - N- -71==-WRITEIBELOW _ _ THIS LINE
Rabies Type: KILLED VIRUS Mfg, pc ----4 PRICE NEXT BOOSTERS Rabies Type: KILLED VIRUS Mfg. () PRICE NEXT BOOSTERS2
Lotit(:) -50(lij 61 \---.) Tag ' (Does not Include a4 12 36 Lot # c-) ) 0 qd q Lil b Tag (Does not incfude 3.4 5 12 36
...-,1 tnostoytog oho) Pitch of boosters.) weeks Months Months Months ' -- c s:/- ti pse<on.,...,5wit.n price of booslers) Weeks Months Months Months
Rabies Date Vaccinated: f -V-4 Rabies Date Vaccinated: _ 2 _,) I I I- 1
Rabies Vaccination Due( / ,-,1 / 1 C")_ $ t -z). (1 r) Rabies Vaccination e: -I /21 / I 5 41 '23
...4
DA2PPv 1 DA2PPv+L t Corona $ - DA2PPv / DA2PPv-FL / Corona $
Bordetella - Nasal / Injectable $ Bordetella - Nasal / Injectable $
Lyme / Rattle Snake $ . _. Lyme I Rattle Snake . -$
Deworming (Protal 50 mg/ml) cc ,$ Deworminq (Protal 50 mq/m1) cc $
Cat 4-in-1 (FVRCP) / Leukemia $ Cat 4-in-1 (FVRCP) / Leukemia $
Heartworm / 3DX / 4DX Test rt Pas ID Neg $ Heartworm / 3DX / 4DX Test El Pos 0 Neg $
FELV/ FIV/Parvo / Giardia Test 0 Pos FINe $ FELV I FIV/ Parvo I Giardia Test] Pos [Ti Neg $
Rx Heartworm Mfg: Rx Heartworm Mfg:
Pet's Weight: El 0-25# 7126-50tt CI 51-100# $ Pet's Weight: El 0-25# n 26-50#171 51-100# $
Flea / Tick Control: $ Flea / Tick Control: $ ,
Micro Chip Mfg. $ Micro Chip Mfg. $
Micro Chip # Micro Chip /I
Other: $ Other: $
Other: $ Other: $
Other: $ Qty: @ $ Other: $ Qty: @ $ _
Other: $ Qty: 0 $ Other: $ Qty: @ $
Treatment Fee: $ Script Fee: $10 $ Treatment Fee: $ Script Fee: $10 $
4. Exam Fee45,)$20 Health Certificate: $25 $ ,`-'1, . () (.) ,y Exam Fee45)$20 Health Certificate: $25 $5
. , Wasia. $2 $3 $ t . C; 0 ,,) Waste Disposal Fee: 41) $2 $3 $ t . 0
HR: /170 Resp: __-ir', , NEXT BOOSTER DUE ON: -1--) i -e--i i \ (--, HR: gQ Resp: S.0 i NEXT BOOSTER DUE ON: 3 i I --,, A ) I 1 I- IC 1.,
Temp: i (11, --7 Weight: 7 C , P NOTES / DOSAGE Temp: i 02 .2 Weight: 4 -5, (1 NOTES / DOSAGE
PHYSICAL EXAM: PHYSICAL EXAM:
Checked Unable lo Check Checked Unabte to Check
Gen. App. 71 CI Gen. App. fl El
Skin El El iro V c__ Skin 0
Eyes El __ ____ -- Eyes El
Ears CI El Ears El
Mouth b 171 Mouth CII
HEALTH WITHIN NORMAL LIMITS HEALTH WITHIN NORMAL LIMITS
Yes a _ No n Yes a No EI
Veterin a rifaxi 044,40,1441 Location: Tech. Init: Fee: $
State Lic Date: Pd $ Bal $ -"C`sh CC Fl cvc ---Cashier hit; 'I"' TOTAL: $ L.1
3616
White: CARING HEARTS VETERINARY SERVICES LLC Yellow: CLIENT I COUNTY
CaringHeart VACCINATION CERTIFICATE 3
Official Proof of Vaccination
Veterinary Services. Keep this record in a safe place. Duplicate requests $10. Corporate Office Hours:
Mon - Fri 9:00 am - 5:00 pm
480-699-9950 P.O. Box 7479 Mesa, AZ 85216
www.caringheartsvetservice.com
Last Name: /4151111211M MI11111 First Name: MIIIIIIE _11111H1111
nylo-DTTITIFFI
Address:
City: State: Ark- Zip: AMOS
I Email: MUM 1111111111,1101110r21311111E1811111111111 0
Home: icso ) DOc,- Cell: ( Work: (
acknowledge having read and I understand the back of this document. Being aware
of these facts, I give my permission to CARING HEARTS VETERINARY SERVICES x
LLC and/or the Doctor to treat and/or administer the vaccinations listed below. w ' ,"I,/Lf DATE / '/ k
New Client CI Existing Client Did you get a reminder card in the mail? ['Yes fl No There is a $1-$3 as e disposal fee per animal. Prescription ONLY fee $10.
How did you hear about this clinic? o Flyer from Store El Promotional Mailer CI Newspaper p Referral 11 TV 1 Radio El Website El Drive By o Other
PET #1 PET #2
0 Dog 7J Ferret -E314.91e •0-Spay/Neut-- 71 Pregnant 171 Dog 17) Ferret [71 Male El Spay/Neut p Pregnant
0 Cat 0 Other faFemale 0 On Medication CI Cat ri OthertWemale El On Medication
3 •
Name: - e rT:u\--e :_------ _-,-- • Age:\3 Cl Wks Name: • U CA. .) Age: kf-C1 w(se)
Breed: k. - Ci. - , r , CI Mos Breed: k &r(- — a, W/Mos
Colors: ) 6, 71 yrs Colors: VINE11.1111111, 13 Yrs
r , FOR OFFICE USE ONLY - PLEASE DO NOT WRI LOW THIS LINE al
Rabies Type: KILLED VIRUS Mfg. L 11 PRICE NEXT BOOSTERS Rabies Type: KILLED VIRUS Mfg. =1[4]LU PRICE NEXT BOOSTERS
Lot # (:) -50 (i 0 q ii b Tag (Dan nol include 3_4 6 2 36 Lol #:: 30 C70 q q1) Tag — (Does !lot tliclu& .1.4 6 12 36
Rabies Date Vaccinated: i 7-1---/-- i .i.r.r...., ---1..V, Price of boOSIer$ ) Weeks Months Months Months . i , i 1 T.,,, r, poce of boosterS.) Weeks Months Moths Months
_ Rabies Date Vaccinated: :1 _
Rabies Vaccination Due: tt / i (/ / I r-, ) $V) if<1 Rabies Vaccination Due: ( I / 1 11 i_f_S41 ' $ t 11 .019
DA2PPv / DA2PPV-I1 / Corona $ DA2PPv / DA2PPviL / Corona $
Bordetella - Nasal / Injectable $ Bordetella - Nasal / Injectable $
Lyme / Rattle Snake $ Lyme / Rattle Snake -$
Deworming (Protal 50 mg/m1) cc $ Deworminq (Protal 50 mg/ml) cc $
Cat 4-in-1 (FVIRCP) / Leukemia $ Cat 4-in-1 (FVRCP) / Leukemia $
Heartworm / 3DX / 4DX Test El Pos El Neg $ Heartworm I 3DX / 4DX Test n Pos El Neg S
FELV lFIV IParvo/ Giardia Test 0 Pos 11 Neg $ FELV1FIV I Parvo/ Giardia Test 0 Pos El Nag $
,
Rx Heartworm Mfg: Rx Heartworm Mfg:
Pets VVeight:1 0-25# 171 26-50# 0 51-100# $ 1M Pet's Weight: El 0-25# n 26 -50# n 51-1004 $
Flea / Tick Control: $ 7 Flea / Tick Control: $
Micro Chip Mfg. $ Micro Chip Mfg. $
Micro Chip # Micro Chip #
Other: $ Other: $
Other: Other: $
Other: Qty: @ $ Other: $ Qty: @ $
Other: $ Qty: $ Other: $ Qty: 0 $
Treatment Fee: $ Script Fee: $10 $ I Treatment Fee: $ Script Fee: $10 $
Exam Fee: pl $20 Health Certificate: $25 $ -.), Cl (...) y Exam Fee: r7$20 Health Certificate: $25 $9, 40
Waste Dispo-S.al Fee: $1) $2 $3 $i, 0 G ,_ Waste DispoSal Fee: 1) $2 $3 $1 , 6' ti
HR. . it,--1- ____ -- Resp: NEXT BOOSTER DUE ON. I ) r i 1 )z.) HR : ) 1. -) (0 Res: p
, NEXT BOOSTER DUE ON: 1 1 1 / ii i
Temp: ) f Weight: .5.14_J, NOTES! DOSAGE Temp: ? (2 .4-:), / /Might 3, t
NOTES / DOSAGE
PHYSICAL EXAM: PHYSICAL EXAM:
Gen. App. lfrahla o to Chnck c-1 e4 Unablo to ChNk
fJ Gen. App. CI
Skin 0 Skin 0
Eyes lfl 0 Eyes 71
Ears n Ears 7
Mouth Fl Mouth El
HEALTH WITHIN NORMAL LIMITS HEALTH WITHIN NORMAL LIMITS
Yes 171: No El Yes Z No El
Veterinarian: t) a"-"4-0(1 g. /311-A"' Location: (tj (9,9 (,), U 1D ( (1'1 Fee: $
State Lic # #36l6 Dato.( 11 ash,9 Cc 0 CVC :ashler Ind: TOTAL: $ q
VVhlte: CARING HEARTS VETERINARY SER ICES-11C Yellow: CLIENT / COUNTY