If you are human, leave this field blank.Name *Pet’s #1 Name *Pet’s # 2 NamePhone *Vaccinations and Testing Due PLEASE NOTE: Rabies, Distemper and Bordetella vaccines are all REQUIRED for ANY PET that is at BHPH for Pet Lodging, Daycare, Bath & Spa Services, or Professional Grooming. If your pet is due for an exam, or if you have any concerns that you would like addressed, then you will need to schedule an exam on a separate date. We do not perform examinations while pets are at BHPH for Pet Lodging, Daycare, Bath & Spa Services, or Professional Grooming. Below are the medical needs of your pet. If you would like any treatments done while your pet is with us for Pet Lodging, Daycare, Bath & Spa Services, or Professional Grooming, then please check them off below. (Check all that apply).Bordetella vaccine ($31.15)Distemper vaccine ($54.80)Rabies vaccine ($47.10) Intestinal Parasite ($66.00)Influenza vaccine ($49.00) Tick/Heartworm Exposure Test ($108.00) Lyme vaccine ($46.15)Feline Leukemia vaccine ($61.40)Feline Distemper vaccine ($38.80)Other TestingOther TestingDisclaimer: *I have read the DISCLAIMER below and agree to its terms.Signature *I acceptBy selecting “I Accept” using any device, means or action, you consent to the legally binding terms and conditions of this Agreement and the Disclaimer. You further agree that your signature on this document (hereafter referred to as your “E-Signature”) is as valid as if you signed the document in writing.Type Your Name to E-Sign: *Captcha *reCAPTCHA is required.SubmitPLEASE NOTEBull’s Head Pet Hospital will NOT be responsible for toys, bedding, medications or prescription diets. Prices above are valid, as of 03/18/2021, and provided for planning purposes, but are subject to change.