WKC 2020 HEALTH CLINIC ONLINE REGISTRATION FORM

WKC HEALTH CLINIC ONLINE REGISTRATION FORM

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Phone*
- This is my cell phone
- This is a LAN line
- This is a work phone
Text Authorization*
- Yes you may text me
- no you may not text me
I authorize you to text me regarding this event and other Waukesha Kennel Club business, notices and other important items.
Email*

For improved communications, we may email you for this event. Waukesha Kennel Club business, notices, and other important items.
Dogs Call Name*
Dogs Breed*
Dogs Date of Birth*
Date Format: MM slash DD slash YYYY
AKC REGISTRATION NUMBER (if applicable)
Check with your national breed club or trusted health advisor regarding age and frequency requirements, for your dogs health clinic service needs.
OFA SERVICES
OFA CARDIAC*
OFA EYE EXAM*
OFA THYROID (includes OFA registration) ($160.00)*
OFA PATELLAR LUXATION*
VACCINATION SERVICES
Rabies (includes brief exam)*
Bring previous Rabies vaccination records with you.
DHLPP OR DHPP OR LEPTO ONLY*
(includes brief exam)
BORDATELLA SHOT*
(includes brief exam)
MICROCHIP*
(includes registration )
HEARTWORM*
(includes lyme, e-canis, anaplasmosis)
HEALTH CLINIC PREFERRED TIME SLOT*
THESE TIMES ARE TO ASSIST US IN SCHEDULING, BUT ARE NOT GUARANTEED. WE WILL DO OUR BEST TO ACCOMMODATE YOUR CHOICE OR TO MODIFY YOUR TIME SLOT TO ACCOMMODATE YOUR SHOW SCHEDULE ONCE YOU ARE ON SITE THE DAY OF THE CLINIC. ADVANCE ONLINE REGISTRATION IS ENCOURAGED TO SECURE YOU SPOT AND WILL CLOSE AT 12 PM ON FRIDAY, FEBRUARY 9, 2018. DAY OF HEALTH CLINIC REGISTRATIONS WILL BE TAKEN IN PERSON UNTIL 12 PM SATURDAY, FEBRUARY 9TH OR UNLESS CLINICS REACH THEIR FULL CAPACITY. CHECK IN AT THE HEALTH CLINIC REGISTRATION DESK UPON ARRIVAL FOR YOUR CONFIRMED TIME SLOT. THANK YOU FOR PARTICIPATING IN OUR HEALTH CLINIC
As with any medical or surgical procedure, there is a slight risk including anaphylaxis that may be associated with these vaccinations procedures. Kindly click on the "I understand"checkbox to acknowledge this vaccination statement and continue with your registration.
*
- I understand
I (we) agree to hold the AKC, the Waukesha Kennel Club, their members, directors, officers, and the owner and/or lessor of the premises and any provider of services that are necessary to hold this event and any employees or volunteers of the aforementioned parties, harmless from any claim for loss or injury which may be alleged to have been caused directly or indirectly to any person or thing by the act of this dog while in or about the event premises or grounds or near any entrance thereto, and I (we) personally assume all responsibility and liability for any such claim; and I (we) further agree to hold the aforementioned parties harmless from any claim for loss, injury or damage to this dog. Additionally, I (we) hereby assume the sole responsibility for and agree to indemnify, defend and save the aforementioned parties harmless from any and all loss and expense (including legal fees) by reason of the liability imposed by law upon any of the aforementioned parties for damage because of bodily injuries, including death at any time resulting therefrom, sustained by any person or persons, including myself (ourselves), or on account of damage to property, arising out of or in consequence of my (our) participation in this event, however such, injuries, death or property damage may be caused, and whether or not the same may have been caused or may be alleged to have been caused by the negligence of the aforementioned parties or any of their employees, agents, or any other persons.
*
- I agree to the above terms
CREDIT CARD IDENTITY*
First Middle Last
To assist us in matching your Health Clinic submission to our Pay Pal records, Kindly add the name as it is listed on the credit card you will be using for your purchased services.
Total
$0.00

WKC 2020 HEALTH CLINIC ONLINE REGISTRATION FORM

WKC HEALTH CLINIC ONLINE REGISTRATION FORM

OFA SERVICES

VACCINATION SERVICES