Cat Lifestyle Assessment Form – Lanoka Oaks Veterinary Center

Client Name *

First

Last

Client #

Phone

Email *

Cat's Name

Date

Is it more convenient for you to respond by

TEXT
EMAIL
PHONE

1. I have the following number of pets

1
2
3
more than 3

2. My pet lives

Inside 100%
Outside 100%
Goes outside, does his/her business and comes back in

3. My pet and I live in a

4. I do or do not travel with my pet in car or plane

Do
Do Not

5. I do or do not take my pet to boarding, bathing, or grooming

Do
Do Not

6. I do or do not show my pet in confirmation

Do
Do Not

7. I am or am not considering adopting or purchasing a new pet

Am
Am Not

8. I do or do not have concerns about contagious disease in neighbor's pets

Do
Do Not

9. I do or do not have young children in the household

Do
Do Not

10. I do or do not have pet insurance

Do
Do Not

11. I am or am not aware of the zoonotic risk to my children or family members by my pet

Am
Am Not

**Zoonoses are any disease that can be passed between our pets and ourselves

I understand that Lanoka Oaks Veterinary Center will use the information provided along with my pet's medical history to make a recommendation regarding my pet's vaccination program *

I have read and understand

I understand that this vaccine protocol has been tailored for my pet's current lifestyle and to reduce the risk of adverse events that may be associated with vaccination. I understand the recommendations on the reverse and (please choose one) *

agree that, to the best of my ability, I intend to follow the recommended vaccination program
disagree with either the nature, timing, or the potential cost of the recommendations and do not intend to follow the recommended vaccination program

If you agree to the recommended vaccination program, please read the following and sign below.

I agree to notify Lanoka Oaks Veterinary Center immediately should my pet's lifestyle change in any way. *

I agree

I understand that the vaccination of my pet based on the agreed upon protocol will substantially reduce but may not completely eliminate his/her chances of contracting disease *

I understand

I understand that should my pet develop any severe or unanticipated reactions after vaccination that I should contact Lanoka Oaks Veterinary Center immediately for instructions. If these unanticipated reactions occur after hours, I will contact the emergency clinic instead. *

I understand

I understand that a lump or bump may form at an injection site shortly after administration. If the lump or bump persists longer than one month after administration of any injectable product, it is my responsibility to contact the clinic and make an appointment to examine the site. *

I understand

I have discussed the protocol with the veterinarian and have asked any questions I have concerning this vaccination protocol. All such questions have been answered to my satisfaction. *

I agree

I /we hereby authorize Lanoka Oaks Veterinary Center to request and record all previous medical records. I authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures. *

Yes, you have my permission.
No, you do not have my permission.

We love social media! Do we have your permission to share your pet(s) image and story on social media,our website & other forms of related media? Your name and personal information will never be shared. Simply check Yes to authorize. *

Yes, you have my permission.
No, you do not have my permission.

Signature of client *

Date *