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Action Care Mobile Veterinary Clinic, LLC
Mechanicsville, Maryland
301-884-PETS (7387)

Immunization Information and Consent Form
Date: ______________________________
          Immunizing your pet is an important procedure that in most cases will provide protection against an illness that may be life threatening.  In past years veterinarians have followed the vaccine manufacturer’s guidelines and recommended annual revaccination for diseases that were felt to be a threat to our patients.  Recent studies have shown that annual revaccination may not be necessary for some diseases because many pets are protected for three years or longer when vaccinated.  Although most pets do not react adversely to a vaccination, some have had allergic or other systemic reactions after receiving a vaccine.  Occasionally the allergic reaction can be so profound that it may be life threatening.  Certain immune mediated diseases such as hemolytic anemia (anemia caused by red blood cell destruction), thrombocytopenia (low blood platelet numbers), and polyarthritis (joint inflammation and pain) in dogs may be triggered by the body’s immune response to a vaccine.  In cats, a serious additional concern has been a “lump” forming at the site of the vaccination caused by a substance in the vaccine called an adjuvant.  In some cats, if these lumps persist, a tumor may form called a fibrosarcoma which may have grave consequences if ignored.  If your cat develops a lump under the skin following a vaccination that persists for longer than four weeks, you should have it examined as soon as possible.
          Your decision to vaccinate your pet should not be taken lightly.  A decision should only come after your pet’s age and the risk of exposure to disease are considered by you and your veterinarian.  Vaccinations given at the appropriate age and at the appropriate intervals will greatly benefit your pet and protect it against some life threatening diseases.
          The following vaccines listed are considered “core” and “non-core” by the AVMA, TVMA, AAHA and Texas A&M College of Veterinary Medicine.  The University of California at Davis and North Carolina State University Colleges of Veterinary Medicine also recommend vaccine protocols that consider core and non-core vaccinations.  All pets should receive core vaccinations with boosters at appropriate intervals to be determined by exposure risk related to your pet’s life style.  Non-core vaccinations should not be used routinely and are only administered if your pet’s exposure risk warrants it.
For additional information regarding vaccinations and your pet, visit the website,
Core vaccinations for dogs:
Core vaccinations for cats:
__Hepatitis (Adenovirus-2)
__Parvovirus enteritis
__Rhinotracheitis (Feline Herpes)
__Panleukopenia (Feline parvovirus)
__Calici Virus
Non-core vaccinations for dogs:
Non-core vaccinations for cats:
__Bordetella (Kennel Cough)
__Lyme  Disease
__Corona Virus (not recommended)
__Giardia  (not recommended)
__FeLV – Feline Leukemia Virus
__FIV -Feline Immunodeficiency Virus (not recommended)
__FIP -Feline Infectious Peritonitis (not recommended)
Please check all of the statements that apply to your pet.
__ primarily indoors
__ indoors-outdoors
__ visits a boarding kennel frequently
__ always outdoors
__ Is groomed frequently
__ (Has)     __ (Has not) had a reaction to previous vaccination
__ has exposure to wildlife (raccoons, opossums, skunks, snakes, etc.)
          I certify that I have read the above information and I am now aware of the risks associated with failure to vaccinate my pet as well as the potential side effects associated with receiving the vaccination.  By signing this consent form I authorize the administration of the vaccinations checked on the form above to my pet.  Because vaccination reactions are not predictable, I agree that the veterinarians at Action Care Mobile Veterinary Clinic, LLC shall not be held liable for any reactions related to the administration of vaccinations administered to my pet.  I further agree to hold my veterinarian harmless when in the event the effort to reduce the frequency and minimize known complications of vaccination inadvertently increases my pet’s risk when exposed to a disease and I shall be responsible for fees related to treating any of the diseases  for which a vaccine was not administered.
Client /Owner____________________________________ Witness __________________________________________