11/07/2026 Vaccination and Wellness Application

Vaccination and Wellness Application

Client Information
Your Name

First NameLast Name
Address

Street Address

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Species
- Dog's Name
- Dog's Breed
- Dog's Weight
  Pounds
- Age (Please specify months and years)
- Dog's Sex
- Dog's Color
- Dog Vaccination
- Cat's Name
- Cat's Breed
- Cat's Color
- Cat's Sex
- Cat's Age
  Please specify months or years
- Cat's Weight
  Pounds
- Cat Vaccinations
- Microchip Number
- Please upload your most recent electric bill, cable bill, or water bill for verification of being a City of Harlingen resident.
  
  If you do not have an electronic copy of a listed utility bill please call 956-216-5220
  Cancelof
- The person whose name the registration is under must be present on the day of the clinic and provide a valid Texas ID or driver’s license. The name on the ID must match the registered participant’s name and the name listed on the utility bill.
  Initials required
- Authorizations
- I certify that I am the owner.
  Initial
- Please note if you select an 8:00am appointment time you will only be seen between 8:00am and 9:30am. If you select a 9:30am appointment time you will only be seen between 9:30am and 11:00pm.
- Appointment
- “Thank you for your application. The Health Department staff will contact you via email with additional details.”
- FOR OFFICE USE ONLY
- Status
Should be Empty: