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Vaccine Decline Form

Name *

First

Last

Email *

Pet's Name *

I, the undersigned owner of the pet named above, have been provided the information that my pet is in need of preventative vaccinations. I decline the appropriate procedures described to me by the staff/veterinarians at Animal Hospital of Lake Villa. I fully understand the following: *

That some vaccine-preventable diseases are common in certain areas and that my unvaccinated pet could easily get one of these diseases from walking or from another dog that has been exposed.
That if my pet does not receive these vaccinations, the consequences may include contracting illness the vaccine is designed to prevent and the outcome included but not limited to may be: illness requiring hospitalization, pneumonia, seizures, deafness, death and/or brain damage.
That my pet's veterinarian, The American Veterinary Medical Association and The American Animal Hospital Association all strongly recommend the vaccinations recommended during today's visit.
That many groomers and boarding facilities will require specific vaccinations and that as such, should I choose to get my pet groomed or boarded may need to come back to get these vaccinations done. I am fully aware that should my pet lose his valid doctor patient relationship or require a rabies vaccine, there may be an additional exam fee should I return for these vaccinations.
I have been informed that the rabies vaccination is required by law and failure to update this vaccine may result in fines from local Animal Control facilities.

Please make sure that all boxes are checked before continuing.

Is This For a Cat, Dog, or Other? *

Cat
Dog
Other

If Other, What Species?

Rabbit, Ferret Etc.

Nevertheless, I hereby decline or defer the vaccine(s) recommended for my pet, as indicated below, by checking the appropriate boxes. I know that failure to follow the recommendations about vaccinations may endanger the life of my pet and others with whom my pet may come into contact with. *

Rabies Vaccine
Distemper Combo Vaccine
Bordetella Vaccine
Lepto Vaccine
Lyme Vaccine
H3N8-H3N2 Vaccine

Nevertheless, I hereby decline or defer the vaccine(s) recommended for my pet, as indicated below, by checking the appropriate boxes. I know that failure to follow the recommendations about vaccinations may endanger the life of my pet and others with whom my pet may come into contact with. *

Rabies Vaccine
RCP Vaccine
Leukemia Vaccine

Signature *

By signing this form, I understand the complications of declining vaccines as provided to me by the staff members at Animal Hospital of Lake Villa and still choose to decline them. I hold both veterinarians and staff harmless should illness, injury or death result from declining the recommended vaccines.

Today's Date *

Comment

Animal Hospital of Lake Villa
101 S. Milwaukee Ave.
Lake Villa, IL 60046

Phone: (847) 356-8387
Text: (847) 356-8387
Fax: (847) 356-2817

Premier Veterinary Group
Emergency: (847) 548-5300

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