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2. Contact Information
   Please complete all sections of the form. Those fields with a red asterisk (*) are required.
4. First Name*
5. Middle
6. Last Name*
8. Street Number*
9. Street Name*
10. Apt/Unit Number
12. City*
13. State*
14. Zip*
16. Phone Number*
17. Phone 2
18. Email*
20. Mailing Address Information
    Complete this area if the mailing address is different than the above contact information.
22. Address1
24. Address2
26. City
27. State
28. Zip
30. Preferred Appointment Day

    1. Wednesday 12:00pm-2:00pm
    2. Thursday 10:00am-12:00pm
34. Animal Information
36. How many animals are you making appointments for?*

    1. One
    2. Two
40. Pet 1 Type (Select one)*

    1. Cat
    2. Dog
41. Pet's Name*
42. Pet's Sex*

    1. Female
    2. Male
43. Pet's Weight (in lbs)*
45. Pet's Color (Primary)*
46. Pet's Color (Secondary)
47. Breed*
49. Pet's Age*
    Pet's Age
    If you don't know the actual age, please enter an estimated age.
50. License # for Dogs
52. Current Vaccination Information

    Please select the vaccinations your pet has completed. If you have a copy of your pet's current vaccination records, please send us a copy. You can upload them using the vaccination records field below or fax or email them. Fax # 925-608-8401. Email: spay@asd.cccounty.us

    *At this time, we are not able to serve pets who have had a previous vaccine reaction. We recommend you obtain your vaccinations from your full service veterinary clinic.

54. Dogs

    1. Rabies
    2. DHPP
    3. Bordetella
    4. Leptospirosis
55. Cats

    1. Rabies
    2. FVRCP
    3. Feline Leukemia
56. Vaccination records
    Upload a copy of your pet's vaccination records. *Please be sure to upload the entire document.
58. Does your pet have a microchip?*

    1. Yes
    2. No
    3. Don't know
59. Do you want to microchip your pet? (Pets need to receive a vaccine to receive a microchip at the Clinic)*

    1. Yes
    2. No
60. Has your pet received their vaccination from CCAS in the past?

    1. Yes
    2. No
    3. Unsure
62. Pet 1: Which vaccinations would you like to receive for your pet during your appointment?

    Select all that apply (NOTE: You will not be able to add additional vaccines or microchips at the time of the appointment.)

    1. Dog: DA2PPV - $19
    2. Dog: Rabies - $6.00
    3. Dog: Bordetella (intranasal) - $19
    4. Dog: Leptospirosis - $19
    5. Dog: Canine Influenza - $25
    6. Cat: FVRCP - $19
    7. Cat: Rabies - $6
    8. Cat: Feline Leukemia - $19
    9. Microchip (dog or cat) - $18
    10. Licensing (dog or cat) - $0-$180 (State law requires licensing of all dogs over 5 months of age)
63. Please let us know any special instructions regarding your pet.
67. Pet 2 Type (select One)*

    1. Cat
    2. Dog
68. Pet's Name*
69. Pet's Sex*

    1. Female
    2. Male
70. Pet's Weight (in lbs)*
72. Pet's Color (Primary)*
73. Pet's Color (Secondary)
74. Breed*
76. Pet's Age*
    Pet's Age
    If you don't know the actual age, please enter an estimated age.
77. License # for Dogs
79. Vaccination Information - Dogs

    Please select the vaccinations your pet has completed. If you have a copy of your pet's current vaccination records, please send us a copy. You can upload them using the vaccination records field below or fax or email them. Fax # 925-608-8401. Email: spay@asd.cccounty.us.

    *At this time, we are not able to serve pets who have had a previous vaccine reaction. We recommend you obtain your vaccinations from your full service veterinary clinic.

    1. Rabies
    2. DHPP
    3. Bordetella
    4. Leptospirosis
    5. Canine Influenza
81. Vaccination Information - Cats

    Please select the vaccinations your pet has completed. If you have a copy of your pet's current vaccination records, please send us a copy. You can upload them using the vaccination records field below or fax or email them. Fax # 925-608-8401. Email: spay@asd.cccounty.us

    *At this time, we are not able to serve pets who have had a previous vaccine reaction. We recommend you obtain your vaccinations from your full service veterinary clinic.

    1. Rabies
    2. FVRCP
    3. Feline Leukemia
83. Vaccination records
    Upload a copy of your pet's vaccination records
85. Pet 2 Does your pet have a microchip?*

    1. Yes
    2. No
    3. Don't know
86. Pet 2 Do you want to microchip your pet? (Pets need to receive a vaccine to receive a microchip at the Clinic)*

    1. Yes
    2. No
88. Which vaccinations would you like to receive for your pet during your appointment?*

    1. Dog: DA2PPV - $19
    2. Dog: Rabies - $6
    3. Dog: Bordetella, intranasal - $19
    4. Dog: Leptospirosis - $19
    5. Dog: Canine Influenza - $25
    6. Cat: FVRCP - $19
    7. Cat: Rabies - $6
    8. Cat: Feline Leukemia - $19
    9. Microchip (dog or cat) - $18
    10. Licensing (dog or cat) - $0-$180 (State law requires licensing of all dogs over 5 months of age)
92. Vaccination Clinic Requirements
    Please read ALL the terms below to ensure that your pet is eligible for vaccinations.

94. Contra Costa Animal Services will be operating our public vaccine clinic on Wednesdays.

96. Scheduling Your Appointment

    Requests for appointments must be submitted online. Staff will call you Tuesday-Thursday to schedule for the following Wednesday clinic. You will be called in the order your request was received. If the clinic is full the week you submit your request, you will be called in the next available week. Only two animals per household can be scheduled at a time.

    **We have limited appointments available. Please consider contacting your full service veterinary clinic if you are not able to get into our Vaccination Clinic in a timeframe that works for you.

98. Appointment Day

    You must be on time for your appointment. If you are delayed, you will need to reschedule. Dogs must be leashed or in carriers and cats must be in carriers. **No exceptions. **Attendance is limited to two people per appointment. 

100. If we are not able to handle your pet for vaccination, we will refund your fees. We are not able to sedate animals. 

102. Agreement*
     I have read and agree to the terms above.
Leave This Blank:


104. 1. Receive an email copy of this form.
105. Email address

     This field is not part of the form submission.

106. Submit Submit and Print

* indicates a required field