Date: _______________

Check-in # __________
Missouri: 1116 E. 59th St KCMO 64110 | 816-353-0940 CSR init: ___________
Kansas: 3722 State Ave KCKS 66102 | www.snkc.net Data entry init: _______

Questionnaire – Please Complete Account #: ___________

1. Have you been here before?  Yes  No Pet Information
2. Has this pet been here before?  Yes  No
Pet name ______________________________________
3. How did you hear about us?
Breed _________________________________________
4. Is your dog spayed or neutered?  Yes  No Color ____________________ Sex ______ Age ______
5. If your pet is NOT spayed or neutered, why?
 Concerned about cost  Health issues
 Want to breed  Age/size
Owner Information
 Other (please explain):
Owner name ___________________________________

6. Is your dog microchipped?  Yes  No Address _______________________________________

7. My dog lives:  Indoor only  Outdoor only  Both City ____________________State _____ ZIP _________
8. My dog’s last flea treatment: ______________________ Phone ___________________ Cell _________________
9. My dog’s last heartworm prevention: _______________
Email ______________________________________________
10. My dog last received vaccinations: _________________

FEES
Great Value Packages - Exam Included S/N
Staff
Don’t forget to upgrade your package to include your desired supply of Advantage Multi! Regular Int.
Discount
New KCMO Client Special Rabies, DA2PP, Bordetella, HW Test, KCMO license & microchip N/A $65
Dog Health Package Rabies, DA2PP, Bordetella & Heartworm Test $75 $50
Puppy Booster DA2PP, de-wormer (hook/roundworms), nail trim + S/N Coupon $25 $25
Rabies Booster – Puppy DA2PP, Bordetella, rabies, 1 HW/FL, nail trim + S/N Coupon $35 $35
Dog Pre-Op Blood Work CBC blood panel + heartworm test + exam $75 N/A

Staff
Individual Services – Brief Exam Required Regular
S/N
Discount Int.
Brief Visual Exam Fee applies per visit for any services not purchased in a package $30 $20
Rabies $25 $18
DA2PP $25 $18
Bordetella $25 $18
De-worming (rounds/hooks) Pyrantel oral de-wormer $10 $5
Drontal Plus Tri-wormer Varies by weight  $15-$40 (altered)  $20-$45 (unaltered) $ $
Heartworm Test Heartworm Test Results:  POS  NEG $30 $25
Advantage Multi – 1 Month Heartworm/flea/intestinal parasite preventative $25/ea $20/ea
Advantage Multi – 6 Month  6-mo supply ($80-$100)  Package upgrade ($35-$45) $ $
Advantage Multi – 12 Month  12-mo supply ($150-$170)  Package upgrade ($95-$115) $ $
Advantage II – 1MO Flea preventative $16 $12
Seresto Collar 8-month flea/tick collar $55 $55
Seresto + Advantage Multi  Seresto + 6-mo supply Advantage Multi ($120-$140)
$ $
Bundle  Seresto + 12-mo supply Advantage Multi ($190-$210)
KCMO Pet License $12 $12
Microchip  Package upgrade ($10) $25 $15
I agree to pay for all charges at checkout. I understand that total charges may exceed my estimated balance pending additional services
requested. I understand that while SNKC does not provide client-veterinarian consultations, my pet will still receive a brief visual exam.

Estimated balance: $ __________ Initials _____________

Cash AMEX Discover Mastercard Visa Amount paid $ __________ Staff initials ______

Spay and Neuter Kansas City no longer approves outside pharmacy prescriptions for any product other than Advantage Multi. As we are not a
full service vet clinic, we are unable to provide a one-on-one veterinary exam to thoroughly educate you on various products available for your
pet’s specific needs. If you are seeking any prescription product other than Advantage Multi, we recommend that you see your full service vet
clinic for assistance.
 OFFICE USE ONLY

Office Use Only

Vaccination labels/notes

Rabies tag # ___________________

City license # ______________________

Microchip sticker goes in dotted line:

Scanned for chip: Yes No NCR

# ________________________________________

Brief physical examination:  WNL  Abnormal

Weight: _______ (if possible)

Sex: S N F M

If male, are two testicles visible? Yes No Other:__________________________________

Puppy/kitten coupon issued?  Yes, expiration date: ____________ No, please issue.

Spay and Neuter Kansas City no longer approves outside pharmacy prescriptions for any product other than Advantage Multi, as
we are not a full service vet clinic providing a one on one exam by a veterinarian who can educate on various products for your
pet’s specific needs. If you are seeking any prescription product other than Advantage Multi, we recommend that you see your full
service vet clinic for assistance.