Vaccine Clinic Registration Form

At Helping Paws Animal Hospital, we are proud to partner with the Helping Paws® Foundation to support our community by providing low-cost and free veterinary care to active-duty military members and veterans and those in need. This community vaccine clinic is designed to make essential preventive care—such as wellness exams and vaccinations—more accessible for all pet families.

As part of this mission, we are honored to extend a special military appreciation benefit. Active-duty military members, veterans, and military spouses who present a valid military ID are eligible for discounted services.

If you or your spouse have a military ID, please be sure to complete the military section at the bottom of this form to ensure the appropriate discount is applied at your visit.

Thank you for trusting us with your pet’s care—and thank you to those who serve. We are honored to support both your family and your pets.

Company

This field is for validation purposes and should be left unchanged.

Owner's Name(Required)

First Last

Number(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Pet's Name(Required)

Species(Required)

Dog

Cat

Breed(Required)

Color(Required)

Spayed/Neutered?(Required)

Yes

No

Sex(Required)

Male

Female

Date Of Birth(Required)

MM slash DD slash YYYY

Microchip #

Pre-Vaccination Examination Requirement

All pets receiving vaccinations will undergo a physical examination prior to vaccine administration, regardless of the date of their last exam. This examination ensures your pet is medically healthy and safe to receive the requested vaccines.

Physical Examination Fee: $28.00

Vaccine Pricing

Canine (K9) Vaccines

Rabies: $24.00

DHPP: $20.00

Bordetella: $18.00

Leptospirosis: $20.00

Feline Vaccines

Rabies: $24.00

FVRCP: $20.00

Feline Leukemia (FeLV): $36.00

Military Appreciation Benefit

Active military members, veterans, and military spouses who present a valid military ID will receive the wellness examination and rabies vaccination at no charge. All other vaccines will be charged as priced.

Vx Reaction History:(Required)

Yes

No

If so, please explain

Please upload previous vaccine history

Max. file size: 128 MB.

Vaccine Release Signature(Required)

Although adverse vaccine reactions are rare, they can occur. In the event that your pet experiences an adverse reaction and needs to be treated at any veterinary medical facility, Helping Paws Animal Hospital, Inc will be held harmless and not responsible for any cost associated with treatment. By proceeding with your vaccinations, you accept this risk. Please contact us if you suspect your pet is having any adverse reaction.

I approve Photo/Video release

By initialing, you grant Helping Paws Animal Hospital (HPAH) , Helping Paws Foundation (HPF) and its representatives permission to take, use, edit, and publish photos or videos of you, your family, and your pet for marketing, social media, and other communications. This includes use on websites, social media, and print materials. You release HPAH, HPF, and its affiliates from any liability related to the use of these images.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Are you eligible for our military benefit?(Required)

Yes — Active Duty, Veteran, or Military Spouse

No

If yes, Please upload valid military ID, valid military dependent ID, or proof of service(Required)

Max. file size: 128 MB.

Vaccine Clinic Date(Required)

MM slash DD slash YYYY

Choose a preferred arrival time:(Required)

1:00 PM – 2:00 PM

2:00 PM – 3:00 PM

How did you hear about us?(Required)

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