Form Center

2. Basic Information

   Story County staff is a small team and we contact applicants back on email. Some email systems send our emails to junk/spam folders. If you have not heard back from us after a few days, be sure to check your spam/junk folder. 

4. Eligibility for the Microchip and Vaccine clinic are as follows:

   Dogs must be on a leash (no retractable/flex-leashes) If your dog arrives on a retractable leash, a flat style nylon leash will be provided for the duration of your appointment.

   If you are bringing more than one dog, they will be seen during the same appointment time with a different student/vet group. If you need to bring a family member or friend with you to assist, please do so.

   Any dogs you sign up for this event must be friendly and able to be handled by staff/volunteers and should not require the use of restraint equipment. Any dogs unable to be safely handled by Story County Staff or volunteers may be turned away.

   Most Importantly, be patient and kind! This amazing opportunity is made possible by volunteers, and they will be working hard to get everyone taken care of. 

6. First Name*
7. Last Name*
9. Address1*
11. City*
12. State*
13. Zip*
15. Phone Number*
16. Email*
20. Animal Information
22. Pet #1
24. Animal Name*
25. Dog or Cat*
    -- Select One --DogCat
26. Color/Description*
28. Pets Gender (select 1 option)*

    1. Neutered Male
    2. Spayed Female
    3. Intact Male
    4. Intact Female
    5. Unknown
29. Breed*

    Listing "MIX" is not acceptable. You must indicate at least one primary breed for your pet.

30. Birthdate*

    If not sure, give approximate age

32. Services Requested*

    1. Rabies Vaccine
    2. Dog DAPPV Vaccine
    3. Dog Bordetella Vaccine
    4. Dog Heart Worm test
    5. Microchip

    Please check each box on which service you would like for your pet. Please note that Dog DAPPV is also known as Dog distemper vaccines. Dog bordetella is for protection against kennel cough. 

34. Pet #2
36. Animal Name
37. Dog or Cat
    -- Select One --DogCat
38. Color/Description
40. Pets Gender (select 1 option)

    1. Neutered Male
    2. Spayed Female
    3. Intact Male
    4. Intact Female
    5. Unknown
41. Breed

    Listing "MIX" is not acceptable. You must indicate at least one primary breed for your pet.

42. Birthdate

    If not sure, give approximate age

44. Services Requested

    1. Rabies Vaccine
    2. Dog DAPPV Vaccine
    3. Dog Bordetella Vaccine
    4. Heart Worm Test
    5. Microchip

    Please check each box on which service you would like for your pet. Please note that Dog DAPPV is also known as Dog distemper vaccines. Dog bordetella is for protection against kennel cough. 

    
    

46. If you need to sign up additional pets, please submit another form after this has been submitted.
48. Preferred Time*

    1. 9:00 am
    2. 9:30 am
    3. 10:00 am
    4. 10:30 am
    5. 11:00 am
    6. 11:30 am
    7. 12:00 am
    8. Whatever time is available

    Please note, we may not have availability at preferred time and will try to accommodate a different time.

50. Comments/Questions
52. Acknowledgements/Agreements
54. I understand that any animal I sign up for this event must be friendly and able to be handled by staff/volunteers. I understand that any animals unable to be safely handled by Story County Staff or volunteers may be turned away.*

    INITIAL ABOVE (Required)

56. I give permission for my pet(s) to receive vaccination services and diagnostic tests from the Story County Animal Shelter and their volunteers. I acknowledge that such vaccinations and services do not constitute complete health care. It is essential that my pet receives a yearly physical examination. I also state that I have provided the Story County Animal Shelters staff and volunteers with any known information regarding my pet’s current health. I have informed Story County Animal Shelter and volunteers of any known illnesses, diseases, or vaccination allergies present in my pet.*

    INITIAL ABOVE (Required)

58. I understand that vaccinations may cause unexpected reactions in pets. I agree to accept all risks of vaccinations and personally accept legal, medical, and financial responsibility for all charges incurred as a result of such risks. I understand that Story County Animal Shelter staff or volunteers cannot provide any follow up care for my pet; in the event of an unexpected reaction, I must seek medical attention from my own veterinarian.

    INITIAL ABOVE (Required if receiving vaccines)

60. I accept that it is my responsibility to seek emergency care for my pet if needed, or as directed.*

    INITIAL ABOVE (Required)

62. I understand that if this the first time that my pet is being vaccinated, he/she may need a booster on the vaccination in order for my pet to be truly protected against disease. The follow up booster will need to be performed at my regular veterinarian. I understand that I will need to follow up with my regular veterinarian for any booster vaccinations needed.

    INITIAL ABOVE (Required if receiving vaccines)

64. If the animal(s) to be vaccinated are intact (not spayed) females: I do not believe this animal to be pregnant. I understand that, should this animal be pregnant, vaccines can cause adverse effects such as stillborn births, premature labor, and birth defects in the unborn fetuses. While the risk of these issues is low, I accept this possible risk.

    INITIAL ABOVE (Required if receiving vaccines)

66. I understand that a Story County Animal Shelter staff member or volunteer will be implanting a microchip into my pet for the purpose of identification. I understand the microchip is implanted under the skin between the pet’s shoulder blades. I understand that the injection needle for implanting the microchip may cause minor bleeding and soreness at the injection site. I understand that the injection site should be monitored for bleeding and kept clean over the course of 3-4 days. If excessive bleeding should occur or if an infection should develop, I will contact my personal veterinarian.

    INITIAL ABOVE (Required if receiving a microchip)

68. I understand my pet will be microchipped with a microchip from PetLink or Buddy ID. I understand that the microchip will be registered with Pet Link or Buddy ID by Story County Animal Shelter staff with the information I provided during sign up. I understand that confirmation that my pet’s microchip has been registered is my responsibility. If I do not receive an email confirmation from PetLink or Buddy ID that my pet’s microchip has been registered, I will follow up with PetLink or Buddy ID using the contact information provided to me at the clinic. I understand that there is no ongoing registration cost to me as long as I remain the owner of the pet and or have a change in contact information up to 1 year. I understand there is a small risk of bleeding and/or infection at the site of the microchip injection. I agree to assume full responsibility for any veterinary care my pet may require as a result of microchip implantation.

    INITIAL ABOVE (Required if receiving a microchip)

70. Release of Liability
72. I hereby consent and authorize the licensed veterinarians, veterinary technicians, veterinarian students and/or their associates utilized by the Story County Animal Shelter and shelter staff and volunteers to provide vaccinations, diagnostic tests, microchips and exams to the pets I bring to this clinic. The Story County Animal Shelter, their officers, directors, volunteers, employees, veterinarians, veterinary technicians, students, or assistants, shall not be held liable or responsible, for any claims, liabilities, losses, damages, charges, fees, and expenses of any nature and character for which I or my animal/animals may sustain or incur by reason or on account of the attending, handling, treatments, vaccinations, or microchipping the animal(s) brought in today. This release relates to any and all liability for personal injuries or death, property damage or property loss, injury or death of any animal occasioned by or in connection with any activity related to this event. I authorize the use of vaccinations, diagnostic tests, or microchipping to be administered as indicated, and I am fully aware of the risks associated, and assume all responsibility. Accordingly, I hereby issue this Release from Liability as it is thoroughly understood, and I have read the aforementioned vaccine reaction information provided to me by the Story County Animal Shelter.*

    INTIAL ABOVE (Required)

74. ATTENTION

    After you submit your sign up form an animal shelter staff member will be reaching out to confirm your registration and time requested. Due to limited spots available we will take sign ups first come, first serve. If you sign up and all spots are taken, We will put you on a wait list incase there are cancellations. This clinic is free and no payment is expected. 

Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field