WOODSTOCK CONSENT FOR ANESTHESIA AND SURGERY

WOODSTOCK SPAY AND NEUTER CLINIC

843 Lane Allen Rd, Lexington, KY 40504 859-277-7729
Name *

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Address *

Street Address

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Primary Phone Number *

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Alternate Phone Number

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Work Phone Number

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Which of the above numbers is the best to reach you on the day of your appointment? *
Email
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Pet Information *

Name Breed Age**
**Though not required, if your pet is over 6 years old it is highly recommended that he or she have a basic bloodwork panel run prior to the day of surgery. This helps to ensure that the organs which process and filter anesthesia are healthy enough for sedation. You can either call our clinic and make an additional appointment for this or have it done by your own vet and ask them to share the results. *

I have read the above and either plan to have pre-op bloodwork done or I accept the risk and hold Woodstock harmless if I do not.
Gender *
My Pet is a *
What was the approximate date of your female dog's last heat cycle? *

Month Day Year
Date
Spaying a dog in heat can come with additional risk. In most cases the surgery can still be done safely. However, if factors are identified at the time of drop-off that would increase these risks to a dangerous level our surgeon reserves the right to reschedule your dog to the earliest that is available once their heat cycle has completed. *

I have read and I understand the policy above.
Color Weight
Does your pet have any health concerns, current or ongoing, that you are aware of? *

Yes No
Date of Scheduled Appointment *

Month Day Year
Date
***PLEASE NOTE*** If you will not be able to keep your appointment for any reason, we require a minimum of 24 hours' notice prior to your appointment or a $25.00 fee WILL be required when/if you reschedule. *

I have read and I understand this cancellation policy.
SERVICE TYPE REQUESTED *

STERILIZATION (Spay or Neuter) DENTAL (Pre-scheduled, this is NOT an add-on option) SEDATED SHAVEDOWN (Pre-scheduled)
Our spay and neuter package prices INCLUDE Rabies and DA2PP vaccines for dogs *OR* Rabies and FVRCP vaccines for cats. (PLEASE NOTE: For other procedures, such as Dentals, Shavedowns and Mass Removals these vaccines are an additional $12.50 each.) Do you want your pet to receive these at the time of surgery? *

Yes, please give my pet these two shots at no additional cost if my pet is being spayed or neutered. I am aware that if my pet is here for a different reason the cost of these vaccines will be $12.50 each. No, my pet is already current on his or her shots (This option will not reduce surgery price).
Additional Services (check all that apply):

Umbilical Hernia Repair (+$30) Heartworm Test (pet over 6 months old only) (+$20) Remove retained baby teeth (+$5 EACH) Bordatella Vaccine (+$15) Leptospirosis Vaccine (+$15) Remove Dewclaws (rear, unattached ONLY) (+$20 EACH) Clip Nails (+$12) Nexgard (chewable tablet for fleas and ticks) SINGLE 30 day dose (+$18 to $20) Nexgard (chewable tablet for fleas and ticks) 3 DOSES (90 day supply) (+ $54 to $60) Elizabethan collar (clear plastic "Cone") (+ $8) Microchip (+$25)
Additional Services (check all that apply):

Umbilical Hernia Repair (+$30) Feline Leukemia / FIV combo Test (+$27) Feline Leukemia Vaccine (Only with proof of Negative Test) (+$15) Clip Nails (Indoor cats only) (+$12) Revolution (topical treatment for fleas & ear mites, lasts 30 days) (+$15 to $18) Microchip (+$25)
If you are asking to have your pet microchipped, Woodstock includes free microchip registration with this service. The microchip company, 24PetWatch, asks for the following information to assist us with that registration. We appreciate your time taken in answering these questions.
Emergency Contact (Someone *other than youself* who can reach you if your pet is found and your primary contact information fails to do so): *

First Name Last Name
Emergency Contact's Phone Number *

Area Code Phone Number
I agree that 24PetWatch may release my contact information to anyone who finds my pet in order to facilitate pet recovery *

Yes, I agree No, I do not agree
24PetWatch offers you free lost pet services, as well as exclusive offers, promotions and the latest information from 24PetWatch regarding microchip and insurance services. I agree that Pethealth Services (USA) Inc. and PTZ Insurance Agency Ltd. may contact me via commercial electronic messages, automatic telephone dialing systems, pre-recorded/automated messages or text messages at the telephone number provided above, including your mobile number. These calls or emails are not a condition of the purchase of any goods or services. I understand that if I choose not to provide my consent, I will not receive free lost pet services which includes being contacted with information in the event that my pet goes missing. I may withdraw my consent at any time. *

Yes, I agree to the above. No, I do not agree.
NOTES (Please use this space if you have questions or need to include additional information regarding your pet.)
In the following situations additional charges are possible with sterilization surgery: In Heat Dog (+$30.00), Pregnant Dog (+$30.00), Undescended Testical (+$30.00), Capstar (For Pets With Heavy Flea Infestation) (+$7.00). By checking the box below I am acknowledging that I have read this information. *

I understand that additional charges are possible that Woodstock and their veterinarians may not be able to advise me of prior to surgery.
All Services must be PAID IN FULL at the time your pet is released from our care. For a smoother checkout experience, payment by credit/debit card over the phone is preferred. *

I Have Read and Understand Payment Requirements
Are you completing this form on a device that would allow you to use a touch-screen for your signature? *

YES NO
By signing below I hereby authorize the veterinarian to treat and/or surgically alter my pet. I understand that physical examinations are given to all animals prior to surgery. I also understand that surgery is trauma to the body and that sometimes unforeseen results can occur. I therefore agree to release the veterinarian and Woodstock Animal Foundation from any and all liability due to any adverse results of such surgical procedure or treatment. I also represent that I am authorized to enter into this Agreement for all persons who own or are authorized to make decisions regarding this pet's care and that such persons will be bound by the terms of this Agreement. *

Clear
Electronic Signature Agreement. By selecting the "I Accept" button and typing your name to the following, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Woodstock Animal Foundation, Inc. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to make decisions regarding your pet's care and that such persons will be bound by the terms of this Agreement. *

I ACCEPT
I hereby authorize the veterinarian to treat and/or surgically alter my pet. I understand that physical examinations are given to all animals prior to surgery. I also understand that surgery is trauma to the body and that sometimes unforeseen results can occur. I therefore agree to release the veterinarian and Woodstock Animal Foundation from any and all liability due to any adverse results of such surgical procedure or treatment. *

I ACCEPT
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WOODSTOCK SPAY AND NEUTER CLINIC