Harley's Paws Park HEALTH PROFILE All dogs must be vaccinated for Distemper, Hepatitis, Parainfluenza and Parvo every 2-3 years as advised by your Veterinarian. The Leptospriosis vaccination is optional. Dogs must be vaccinated for Rabies in compliance with Health Department regulations with a one, two, or three year vaccination. All dogs must have a yearly health exam by a licensed Veterinarian which includes a yearly fecal analysis (stool sample). Should an owner notice any sign of illness, hair loss, fleas, ticks, or change of temperament in their pet, they should not bring their dog to the park until the situation is resolved. Please print this form and have your Veterinarian sign and stamp the application and return it to Harleys Paws Park, PO Box 284, Westhampton Beach, NY 11978. Thank you for your cooperation! NAME OF OWNER ________________________________________________________________ ADDRESS _______________________________________________________________________ Street City Zip TELEPHONE _____________________________________________________________________ Day Phone Home Phone NAME OF DOG _______________________________ BREED ___________________________ AGE ____________ SEX _______________ WEIGHT _________________ TO BE COMPLETED BY LICENSED VETERINARIAN CERTIFICATE OF IMMUNITZATIONS Required every 2-3 years: VACCINATION DATE GIVEN DATE EXPIRES Distemper ___________ _____________ Hepatitis ___________ _____________ Parainfluenza ___________ _____________ Parvo ___________ _____________ Lepto (optional) ___________ _____________ CERTIFICATE OF RABIES RABIES TAG NUMBER ________________ DATE VACCINTATED ___________ EXPIRES ____________ PRODUCER ______________ VACCINE SERIAL NUMBER ___________________ STOOL SAMPLE DATE PERFORMED ____________________ RESULTS ______________________ PLEASE STAMP THE NAME TO THE VETERINARY HOSPITAL OR CLINIC ___________________________ ______________ Signature of Licensed Veterinarian Date |
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