Rat Lungworm Disease in Hawaii

In November and December 2018, two young dogs in the Honolulu area were diagnosed with Rat Lungworm Disease, caused by Angiostrongylus cantonensis. Both puppies presented with spinal hyperesthesia, hindlimb weakness, and proprioceptive ataxia. One dog had peripheral eosinophilia; all other hematology and serum biochemistry tests were unremarkable. Plain radiographs and computed tomography scans (with/without) contrast were performed but did not reveal a cause for the neurologic signs. Cerebrospinal fluid analysis in both patients revealed eosinophilic pleocytosis and real-time PCR testing for Angiostrongylus cantonensis on CSF was positive in both dogs, confirming a diagnosis of neural angiostrongylisias; PCR testing for other canine neural pathogens was negative.

Both dogs responded rapidly to treatment with corticosteroids and recovered clinically within 2 weeks. Neither dog was observed ingesting a snail or slug, but both dogs had environmental access to them. Dr. Richard Malik (University of Sydney) spoke on this topic in May 2018 and recommends treating with corticosteroids (up to 6 weeks), +/- anthelmintics (if early infection when the larvae are still small and not yet in the CNS), and pain medication or other symptomatic care as needed. He also recommends antibiotics to address the issue of translocated bacteria carried by migrating larvae.

If you have any suspected cases or have questions regarding diagnosing, treating, or preventing rat lungworm infection in dogs or other animals, please call Dr. Jenee Odani (Extension Veterinarian) at 808-956-3847 or email jsodani@hawaii.edu. She is especially interested in conducting post mortem testing on suspected cases.

Submitted by:
Jenee S. Odani, DVM, DACVP
Associate Specialist: Veterinary Extension
Pre-Veterinary Medicine Program Advisor
College of Tropical Agriculture and Human Resources/HNFAS
University of Hawaii

Hawaii Veterinary Emergency Response

HVMA is working with the Hawaii Emergency Management Agency (HI-EMA) to support local and state disaster preparedness pertaining to animals. Would you be interested in volunteering in the event of an emergency? Would you be interested in being part of the working group developing a set of guidelines for animal care and treatment and considering the formation of a Veterinary Medical Reserve Corps or Companion Animal Response Team? Please help us gauge member interest by taking our survey below.

Hawaii Rabies Quarantine Changes

Rule amendments to Chapter 4-29, HAR recently received final approval from the Governor and will become effective on August 31, 2018. A summary of the more significant changes follows. The complete Chapter 4-29, HAR with amendments is located on the Hawaii Department of Agriculture’s website at: http://hdoa.hawaii.gov/ under the Administrative Rules tab. The Animal Quarantine information page (access by clicking on the Animal Quarantine tab) has been updated and new checklists added to assist with preparing a dog or cat for the 5 Day or Less program and Direct Airport Release.

Exact Changes Made:

A. Section 4-29-2 Definitions
The definition “Service Animal” is added and the definitions of “Service Dog” and “User” are amended to reflect the definition of service animals under current Federal ADA language.

The definition “Eligibility Date” or “Eligible Date” is added for clarification of terminology and means the date determined by the State that an animal may qualify for five day or less quarantine by meeting all the specified requirements.

“Qualification date” is added for clarification and means the date determined by the state that an animal may be released from quarantine by meeting all the specified requirements under Chapter 4-29, HAR.
The definition “Safeguard” is added and means to confine and handle animals so that the animals shall not come into physical contact with any other animal, or cause a potential human exposure, at any time. The location and method of confinement and handling shall be approved by the state.

“Veterinary Hospital” is added for clarification and means an office or building designated for the sole purpose of providing veterinary examinations, diagnostics, and medical and surgical treatments of animals operated by a veterinarian licensed to practice in Hawaii.

B. Section 4-29-8.1 Other requirements
Changes are made to: Reduce the minimum time required from the most recently administered rabies vaccine before arrival in Hawaii from 90 days to 30 days;

Modify the minimum time required from a successful OIE-RVA test by reducing the period from the test before arrival in Hawaii from 120 to 30 days; and

Another amendment is added that owners are required to register their pet’s microchip number with the local county humane society or local animal welfare organization. Other changes are made throughout the section for clarification.

C. Section 4-29-8.3 Movement of dogs and cats requiring urgent diagnostic, medical or surgical procedures not available in Hawaii
A new subsection (b) is made to establish requirements for the importation of cloned animals derived from donor tissue originating in Hawaii into the state without quarantine. This provision allows application of advances in science and technology to qualify as a low risk category for import. Requirements for the cloning facility, veterinary management, brood stock, clone animal preparation, transportation and procedures are included.

J. Section 4-29-11 State animal quarantine station
Changes add that admission to the station may be denied to anyone that is not listed as an owner, co-owner, registered handler or authorized visitor on the record of an animal quarantined in the quarantine station. This change will increase biosecurity and minimize the potential of introducing diseases into the station.

An amendment is added to clarify that station veterinarians are authorized to refer an animal to a veterinary facility for diagnostics and treatment not available at the Station with or without prior owner authorization or approval. This is for situations when owners are not available and/or referral is in the best interest of the animal.

K. Section 4-29-17 Fees at the animal quarantine station.
Changes are made to fees for Five-day or less quarantine, Direct airport release, Neighbor Island Inspection Permit (NIIP) and Re-entry fee with direct airport release and ground transportation on Oahu are made. The total new fees for Five­day or less quarantine being $244 (currently $224); Direct airport release total fee of $185 (currently $165); NIIP fee of $165 (currently $145), and Reentry fee with direct airport release of $98 (currently $78).

L. Throughout Chapter 4-29, HAR, the term “service dog” is changed to “service animal” to reflect current Federal ADA language.

Read full press release here

 

Feline Fix by Five Campaign

Why the change in recommended age of sterilization of cats?

Philip A. Bushby, DVM, MS, DACVS

In June of 2017, the AVMA formally endorsed the consensus document put forth by the Veterinary Task Force on Feline Sterilization for Age of Spay and Neuter Surgery, which recommends cats not intended for breeding be gonadectomized by five months of age. This joined endorsements from other veterinary medical and cat breeding associations including the
American Association of Feline Practitioners, Association of Shelter Veterinarians, American Animal Hospital Association, Winn Foundation, Catalyst Council, Cat Fancier’s Association and The International Cat Association. Feline Fix by Five (FFF) is a campaign promoted by the
Marian’s Dream Foundation to share this recommendation that has garnered such broad support. FFF was born out of awareness that cats can be reproductively active by 4 to 5 months of age, yet most veterinarians recommend spay/neuter of cats at 6 months of age or older. The
result of this mismatch between age at which cats can become pregnant and the recommended age of sterilization is demonstrated any time one walks into a local animal shelter.

Animal shelters are generally overrun with kittens, the vast majority of which are the result of unplanned and unexpected pregnancies of young cats. A survey conducted in the State of Massachusetts revealed surprising results. While many people believe that pet-overpopulation is the result of pets that are left intact for their entire life, the opposite is true. Cats that were eventually spayed accounted for 87% of all litters born. [1]

Cat owners who are unsure of when to have their cat sterilized or simply wait until 6 months of age or later are faced with the dilemma of what to do with an unexpected litter of kittens. Too often those kittens are relinquished to local shelters and too often those kittens are euthanized. The problem was not that the owners refused to spay or neuter their pet; it was that they didn’t have it done in time.

Esther Mechler of the Marian’s Dream Foundation, who initiated the FFF campaign, has stated that “the number of births prevented – simply by changing the recommended age for spay/neuter of cats from 6 months to between 4 and 5 months – could reduce the numbers of shelter intakes enough to balance the number of potential adopters with available cats and
kittens. We could end the overpopulation of cats by this one simple change.” [2]

As a profession, we need to recognize that there is, at present, no scientifically sound basis for waiting until 6 months of age or older to sterilize cats and no contraindications for spay/neuter at 4 to 5 months of age. Anesthetic concerns about juvenile surgery voiced in the 60s and 70s
are no longer valid. There are many anesthetic drugs and protocols in use today that are safe in cats as young as 6 weeks of age. Old fears that castration of juvenile male cats would predispose to urinary obstruction were disproven in the 90’s. [3]

There are numerous known health benefits for spay/neuter in cats, in addition to the population management benefits, and there is “no evidence to suggest that pediatric gonadectomy by 5 months of age is linked to any
increased risk of disease.” [4] A survey conducted in 2000 of veterinarians who were, at that time, spaying and neutering cats under 5 months of age, confirmed that the surgeries were easier, faster, and had fewer complications than spay/neuter of cats at 6 months of age or older. [5]

So, what should the practicing veterinarian do to make this change? Simply add one more appointment to your standard kitten wellness protocols. Make no changes in current vaccination and parasite control recommendations except add an appointment for spay/neuter two to three weeks after the last kitten vaccination. Owner compliance will be increased,
surgeries will be easier, and, in time, local shelters will not be overrun with kittens.

For more information on Feline Fix by Five go to http://www.felinefixbyfive

For more information on the AVMA’s position on spay neuter go to
http://www.avma.org/spayneuter

1. Manning MM & Rowan AN, Companion animal demographics and sterilization status: Results from a survey in four Massachusetts towns. Anthrozoos 5 (3).
2. Esther Mechler, Personal Communication, October 25, 2017.
3. Stubbs WP Scrugges SL, et al BMS. Prepubertal gonadectomy in the domestic feline: Effects on skeletal, physical and behavioral development. Vet Surg. 1993;22.
4. Dale S. When to Spay/Neuter Cats? Vet Consensus Says Fix by Five Months. Vet Pract News. 2016.
5. Land TDVM, Wall SDVM. Survey of the Coalition of Spay/Neuter Veterinarians. J Am Vet Med Assoc. 2000;216(5).

The Use of Drugs in Food Animal Species

Christie Balcomb, BVSc, DACVIM
YourVet Maui
1476 S. Kihei Rd, Kihei, HI 96753
(808) 879-5777
Email: Christie@yourvetmaui.com

The use of medications in food-producing animals can have some challenges, as current demographics seem to be shifting for more people to have livestock as pets and other food-producing animals that are treated more as companion animals than in the past. Livestock are being kept as pets in more urban settings and will likely be seen by veterinarians that treat solely companion animals. Some owners are more willing to pursue medical and surgical treatment for these animals such as backyard chickens or pet goats. However, the Federal Drug Administration (FDA) designates “food animals” as any species that are raised and used for food production or consumption by humans. The species considered to be Major food animal species include: Cattle, Swine, Chickens and Turkeys. Minor species include sheep, goats, camelids, aquaculture species and honeybees, and rabbits. There are several important regulatory distinctions made between Major and Minor food animal species.

“Food-producing animals” are animal species or classes that are used to create a food or food by-product that does not require slaughter, such as milk (also used to make cheese and butter), eggs and honey.1

It is important to note that the FDA does not recognize the owner’s intended purpose of the animal, such as companion miniature pigs versus commercial pig breeds, and all fall under the classification as a Major food animal species. So, even if the animal is considered by the owner as a pet, rather than a production animal, the government regulations and restrictions still apply. Unfortunately, veterinarians cannot always guarantee the outcome and disposition of an animal for the rest of its life.

Extralabel drug use (ELDU) is allowed under the American Medicinal Drug Use Clarification Act (AMDUCA) of 1994, as long as certain requirements are met, including the existence of a valid Veterinary Client Patient Relationship (VCPR). 2-4

Extralabel use is defined as the use or intended use of a drug that is not in accordance with the approved labeling in regards to:

  1. Species
  2. Indication
  3. Dose rate
  4. Dose frequency
  5. Route of administration

For ELDU in Food Animal Species, the following requirements must be met:

  1. There is no approved animal drug labeled for use for that species, indication, dose rate and concentration. [An approved human drug must not be used in extralabel fashion if an approved animal drug exists that can be used in an extralabel fashion]
  2. There must be a diagnosis based on evaluation of the condition suspected
  3. Establish an appropriately extended withdrawal time prior to sale or consumption of milk, eggs, meat or edible products
  4. Maintain records to identify the treated individual
  5. Take precautions to ensure that the established extended withdrawal times are met to prevent any violative residues are found in products to enter the food chain

As clinicians, we are often faced with challenges, as many of the species that we treat are not listed on the label of many veterinary medications, and thus we need to use drugs in an extralabel fashion.  As such, we are also very dependent on scientific data and utilizing the Food Animal Residue Avoidance Database (FARAD) is an essential tool to ensure that we are following the appropriate requirements of ELDU as defined by AMDUCA.

FARAD is a USDA-funded university-based consortium that is overseen and operated by faculty and staff within the Colleges of Veterinary Medicine at the University of California-Davis, the University of Florida, Kansas State University, North Carolina State University and Virginia-Maryland College of Veterinary Medicine. FARAD is a great resource for veterinary practitioners to provide guidance and advice to avoid violative residues in animal products intended for human consumption. The program provides a hotline for requests, as well as online submission of withdrawal times, and a wealth of information on the use of medications in both major and minor use species.  It is highly recommended for any extralabel drug use in a food animal or food-producing animal species to submit a request for appropriate withdrawals to avoid violative residues. For example, the labeled dose rate of procaine penicillin is considered now to be subtherapeutic, and thus it is common for clinicians to use much higher dose rates or frequency of administration, and thus the withdrawal times can extremely prolonged compared to what is listed on the label.5 Current updates on prohibited and restricted drugs used in food animals can be found on their website: http://www.farad.org/prohibited-and-restricted-drugs.html.

The purpose behind many of the major and minor designations and regulations is to protect public health and food safety. Drugs and drug classes that have been prohibited for use in these species have been found to cause potential disease or harm to humans through exposure, or do not have an acceptable analytical method established. Other restricted drugs include classes of antimicrobials that are considered important for human health, and extralabel use of these medications may put the public at risk if antimicrobial resistance develops. In the next few years, it is likely that these regulations will grow to include other antimicrobial classes, or restrict their use further in an attempt to slow the tide of antimicrobial resistance in bacteria.

Violations of these regulations could end up with a consequence of drug residues in food products, which may have health implications for the humans consuming these products. Any products sold to the product could be considered a liability issue due to sale of an adulterated product into the human food chain.6 For those food animals considered as pets, administration of a prohibited antimicrobial may result in transmission of bacteria with resistance to that microbial to the rest of the flock or to the owners, themselves. Other options of antimicrobials with similar spectrum of activity may be available to use in ELDU, rather than these prohibited drugs.

In conclusion, as veterinarians that may practice on both companion and production animals, it can be challenging to adhere to FDA regulations for certain medications, such as the prohibition of any ELDU of fluoroquinolone antibiotics in any food animal species. It can also be uncomfortable to mention the term “food animal” species to a client who has a sanctuary for farm animals that will not be entering the food chain, and some clients may be offended. However, as part of the ELDU requirements, keeping records with some acknowledgement of withdrawal times for food products must be written. It may be more palatable to clients if there is a written statement about the FDA requirements based on species, but understanding that this animal is considered a pet. Finally, FARAD can be an extremely useful resource in case of determining withdrawal periods in case of historical administration, or pre-emptive research to provide the best estimate based on scientific literature. The FARAD digest publications have useful summaries of ELDU in backyard poultry, small ruminants and other species.6-10 FARAD is not a regulatory or governing body, but a program to help support veterinarians maintain public health and food safety.

FARAD Contact Info
Website: www.farad.org
Hotline: 1-888-873-2723

Please also feel free to contact Extension Veterinarian Jenee Odani to discuss any issues: jsodani@hawaii.edu or (808) 956-3847.

Drug or drug class Special considerations
Antiviral drugs – adamantane and neuraminidase inhibitors Prohibited ELDU in all poultry
Cephalosporins Except for cephapirin, any ELDU in MAJOR species (cattle, swine, chickens, turkeys) is prohibited. ELDU in MINOR use species is permitted.
Chloramphenicol Any use is prohibited in food animals
Clenbuterol Any use is prohibited in food animals
Diethylsilbesterol (DES) Any use is prohibited in food animals
Fluoroquinolones ELDU is prohibited in all food animal species (MAJOR and MINOR)
Gentian Violet Any use is prohibited in food animals
Glycopeptides Any use is prohibited in food animals (e.g. vancomycin)
Indexed drugs 11 Some use permitted in MINOR species
Medicated feeds Any ELDU prohibited – Veterinary Feed Directive 2017
Nitrofurans Any use is prohibited in food animals (e.g. topical use of nitrofurazone)
Nitroimidazoles Any use is prohibited in food animals (e.g. metronidazole)
Phenylbutazone Prohibited in dairy cattle >20 months
Sulfonamides * Use in milking sheep and goats is discouraged; Prohibited in dairy cattle >20 months, except for approved labeled use
Table adapted from FARAD http://www.farad.org/prohibited-and-restricted-drugs.html, updated 7/16/2018

 

References:

  1. FARAD. Available at www.farad.org. Accessed on 9/30/2018.
  2. US FDA. Animal Medicinal Drug Use and Clarification Act (AMDUCA) 1994. Available at: https://www.fda.gov/animalveterinary/guidancecomplianceenforcement/actsrulesregulations/ucm085377.htm. Accessed on 9/30/2018
  3. Extralabel drug use in animals. 21 CFR 530.
  4. AVMA. VCPR. Available at: https://www.avma.org/KB/Resources/Reference/Pages/VCPR.aspx. Accessed 9/30/2018.
  5. DeDonder KD, Gehring R, Baynes RE et al. Effects of new sampling protocols on procaine penicillin G withdrawal intervals for cattle. JAVMA 2013, 243:10, 1408-1412.
  6. Marmulak T, Tell LA, Gehring R et al. Egg residue considerations during treatment of backyard poultry. JAVMA 2015, 247:12, 1388-1395
  7. Webb A, Baynes RE, Craigmill AL et al. Drugs approved for small ruminants. JAVMA 2004, 2224:4; 520-523
  8. Baynes RE, Payne M, Martin-Jimenez T et al. Extralabel use of ivermectin and moxidectin in food animals. JAVMA 2000, 217:5, 668-671
  9. Riveiere JE, Tell LA, Baynes RE et al. Guide to FARAD resources: historical and future perspectives. JAVMA 2017, 250: 10, 1131-1139
  10. Davis JL, Smith GW, Baynes RE et al. Update on drugs prohibited from extralabel use in food animals. JAVMA 2009, 235:5, 528-534
  11. US FDA. Index of legally marketed unapproved new animal drugs for minor species. https://www.fda.gov/AnimalVeterinary/DevelopmentApprovalProcess/MinorUseMinorSpecies/ucm125452.htm. Accessed 9/30/2018.

 

ALERT: Police Impersonator Scams

Please note there have been multiple reports of a scammer calling local vets’ offices and cell phones impersonating the police. They have used the name of Captain David Chang.

The Honolulu Police Department recommends that if a veterinarian receives a phone call from a police officer to be wary and ask for their badge number and office phone number. Do not give out any personal information. Then call HPD (or your local county police department) and verify that information before returning the phone call to their office. If you suspect an impersonator, call 911 and file a police report.

AVMF Extends Disaster Relief to Hawaii Veterinarians

AVMF Disaster Relief and Reimbursement Grants

 The American Veterinary Medical Foundation (AVMF) provides two grant programs to help veterinarians and the animals they care for during times of disaster. Grants are available to support victims of hurricanes, floods, tornadoes, earthquakes, volcanoes, wildfires or oil spills.

 Disaster Reimbursement Grants for Veterinary Medical Care

Purpose: The AVMF disaster reimbursement grants are for the purpose of ensuring the emergency veterinary medical care of animal victims of disaster.

 Awards: Up to $5,000 may be issued per grantee for out-of-pocket expenses incurred by veterinarians providing emergency veterinary medical care to animal victims of disasters.  AVMF reimburses for the actual cost of medical supplies purchased directly from a vendor. Modest boarding costs may also be covered. 

Disaster Relief Grant for Veterinarians

Purpose: The AVMF disaster relief grants are for the purpose of assisting veterinarians who have experienced an emergency need for basic necessities due to a disaster. The grants would cover items such as clothing, temporary housing, transportation and meals that were needed immediately following a disaster.

 Awards: Up to $2,000 may be issued per grantee for out-of-pocket expenses incurred immediately following a disaster. AVMF reimburses for the actual cost of items purchased directly from a vendor. Modest housing costs may be covered for emergency temporary shelter.

 Application Procedure

The applications are posted on the AVMF website. Applicants should follow the online directions for submitting the application and the expense chart. Limited funds are currently available and approved on a first come, first served basis.

Deadline:  Applications must be received no later than 120 days following the disaster.

 More Information: Please contact Cheri Kowal, Senior Manager, Programs and Operations, 847-285-6691 or CKowal@AVMA.org

RVT Applications Now Available Online

Applications for licensing registration as a RVT in Hawaii are available online here.

Senate Bill 2671 passed in 2016 which set the following requirements to qualify as a veterinary technician in Hawaii:

  1. Be at least 18 years of age
  2. Have successfully passed the Veterinary Technican National Examination
  3. Meets at least ONE of the following conditions:
    1. Has successfully completed a course of study at a program for veterinary technology accredited by the AVMA committee on Veterinary Technician Education and Activities;
    2. Be licensed, certified, or registered veterinary technician in good standing in another state having standards for registration comparable to those in this State; or
    3. Prior to July 1, 2021, submits a notarized document from an employer who is a licensed veterinarian and who certifies that applicant has five or more years of practical experience in Hawaii; provided that no reciprocity shall be given for practical experience gained outside of the State.

Information for licensing in Hawaii can be found on the Department of Commerce and Consumer Affairs Professional and Vocational Licensing website. Additional information can be found at the HVTA website. Information about the VTNE can be found here.

RVT in Hawaii Meeting May 15, 2018

The Hawaii Veterinary Technician Association (HVTA) is holding a general meeting on Tuesday, May 15, 2018, to discuss RVT in Hawaii, the application, and the grandfathering process. Members and non-members are invited to attend. Please RSVP by May 10th to hvta.info@gmail.com. The meeting will be held at the Kalihi-Palama Library.

Senate Bill 2671 passed in 2016 which set the following requirements to qualify as a veterinary technician in Hawaii:

  1. Be at least 18 years of age
  2. Have successfully passed the Veterinary Technican National Examination
  3. Meets at least ONE of the following conditions:
    1. Has successfully completed a course of study at a program for veterinary technology accredited by the AVMA committee on Veterinary Technician Education and Activities;
    2. Be licensed, certified, or registered veterinary technician in good standing in another state having standards for registration comparable to those in this State; or
    3. Prior to July 1, 2021, submits a notarized document from an employer who is a licensed veterinarian and who certifies that applicant has five or more years of practical experience in Hawaii; provided that no reciprocity shall be given for practical experience gained outside of the State.

Information for licensing in Hawaii can be found on the Department of Commerce and Consumer Affairs Professional and Vocational Licensing website. Additional information can be found at the HVTA website. Information about the VTNE can be found here.

Addendum May 26, 2018: Hawaii RVT application online here.

Hawaii Pet Expo May 12-13, 2018

Volunteers Needed!

The Hawaii Pet Expo is sponsored and organized by the HVMA and will be held from May 12-13th this year. It has been an annual event for over 25 years and is FREE and well received by the public, with an average of 10,000 people attending each year.  The purpose of the Expo is to promote responsible pet ownership and strengthen the bond between people and their pets through educational displays, live animal demonstrations, and the latest in pet services and products.  The HVMA is looking for veterinarians who will promote our profession in a positive manner and educate the public on the need for professional veterinary care. If you are willing to volunteer your time to promote our profession and interact with the public, please sign up!

  • HVMA Booth: Veterinarians will be on site to guide visitors through our booth featuring The Year of the Dog, as well as answer questions from the public.
  • Make and Take (Kiddie Craft) Booth:  Assist kids and their parents with making finger puppets and other paper crafts to take home.  Keep booth clean and organized.
  • Greeters:  Pass out programs and poop bags at the door.  Help to direct traffic in and out of the Exhibition hall.  Smile and welcome people.
  • Information Booth:  Help direct people to exhibits, answer questions, make announcements, store lost and found items, collect food and monetary donations for the Hawaii Food Bank, prep poop bags, run errands, coordinate volunteers, and help clean up pet messes that are reported or seen.
  • Show Marshals:  The “Poop Patrol”.  Patrol Exhibition Hall and grounds outside, picking up pet messes.  Empty overflowing trash and cigarette bins outside hall and transfer to dumpster in back.  The good thing about show marshaling is that you get to walk around the hall and check out all the exhibits, although you are supposed to be working, not shopping during your shift!  We always need a lot of show marshals.

Click here to sign up online.

Saturday and Sunday the shifts are as follows:  9:30-12:00 am, 11:30 to 2:00 pm, and 1:30 to 4:00 pm. Please indicate your t-shirt size (M, L, or XL) at sign up to receive a  Pet Expo t-shirt. Name tags will be provided. Vets are encouraged to wear lab coats or smocks to identify themselves as veterinary professionals.

 

Volunteers should sign up online or by calling Ohana Vet Hospital at 845-1762. Paper sign up sheets may be faxed to 848-1632.