Free Vaccines Enrollment Form — Lake Stevens Animal Hospital

Free Vaccines For Life

Online Enrollment Form

Please initial each term of the agreement, provide the additional requested information and click the button to submit. We will contact you when your application has been reviewed to collect payment and obtain your signature in our office.

We love offering this program and hope it helps simplify the annual vaccination process so you can provide optimal wellness care for your pet.

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Jot Form

1. Enrollment Fee: Client pays an enrollment fee of $___ (staff initials_________) for each pet they wish to enroll in the Free Vaccines for Life Program (FreeVax).

2. Non Refundable: The enrollment fee is not refundable under any circumstances. (i.e. – moving, changing veterinary clinics, death of pet, adopting pet to another family or any other circumstance).

3. Non Transferable: The enrollment fee is for one pet only and is not transferable to another pet or another owner under any circumstance.

4. Annual Wellness Exam (AWE) Requirement: Enrolled adult pets will continue to receive vaccines listed on this form free of charge for the rest of the pet’s life as long as the pet has an annual wellness exam (AWE) within 30 days of when the AWE is due, even if no vaccines are due. This means you have 30 days prior to and after the due date of the AWE. Lake Stevens Animal Hospital (LSAH) gives out reminders to clients via mail, email and text messaging, reminding you of when your pet’s AWE is due. Reminders via email and text messaging are given when clients sign up for our free app with PetDesk.

5. Tech Eval Requirement

Enrolled puppies or kittens will continue to receive vaccines listed on this form free of charge for the rest of the pet’s life as long as the puppy or kitten has a technician exam (tech eval) every 3-4 weeks after the initial AWE, for the duration of the boostered vaccines.

6. AWE Location

AWE’s done at other vet clinics/hospitals will not count toward this program.

7. Program Disqualification

If the pet does not come in for the AWE within 30 days of the due date, then the pet is dropped from the program. If puppy or kitten does not come in for the tech eval within 3-4 weeks after the initial AWE and/or the first tech eval, then the puppy/kitten is dropped from the program. The client can re-enroll the pet by paying a re-enrollment fee, if the program is still offered by LSAH.

8. Right to Refuse Service

LSAH has the right to stop enrolling new pets, or re-enrolling pets that do not come in for AWE. However, once a pet is enrolled and comes in for an AWE, that pet will receive Free Vaccines for Life. Exception: LSAH reserves the right to refuse service to any client/patient that they feel is not the right fit for this practice and/or is a safety concern for its staff members.

9. Rabies Requirement

At the AWE, the veterinarian will discuss the vaccines appropriate for the age and lifestyle of that pet and recommend a vaccination program. The client has the right to refuse vaccines or request additional vaccines that are listed on this form. However, if the Rabies vaccine is not kept current LSAH has the right to refuse service to the client for the health & safety of its employees. Any vaccine not listed on this form is not included in the FreeVax and will be charged upon administration.

10. Additional Fees

All Dr. exam fees, tech exam fees, lab fees, medications, heartworm & flea prevention, and all other vet charges are not included in this program. You are responsible for the AWE fee, tech eval fee and all other charges the day your pet is getting his/her FreeVax. Client must pay for the AWE or tech eval fee in order for the pet to receive the free vaccines. Only the vaccines that are listed on this form are free.

11. 30-Day Application Window

If you choose not to enroll in the FreeVax program at the time of your pet’s AWE, then you have 30 days after the AWE to come back in and enroll in the program. A tech eval or Dr. recheck fee will apply.

12. Included Vaccinations

Vaccines included in the FreeVax are: DOGS • DHPP • Lepto • Bordetella • Rabies CATS • FVRCP • FELV • Rabies

Pet Name

Pet Date of Birth

YYYY

Name of Pet Owner

First Name

Last Name

Microchip

To be completed by LSAH staff.

Pet Description

To be completed by LSAH staff.

Date Application Accepted / Staff Name

To be completed by LSAH staff.

Client Signature

Signature to be obtained in office.