Program Participant Intake and Consent Form

Clinic Participant Intake and Surgical Release
Owner Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
E-mail
Pet 1 Name
Pet 1 Age (include weeks, months or years, approx is ok if you don’t know age)
Pet's Age, an approximate is OK.
Pet 1 Birthdate (only if known)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Pet 1: Health, Vaccinations, Flea and Ear mite treatment. Please give us as much information on when treatment/vaccinations were given. Vaccine records will also need to be submitted.

Rows	Yes/No	Expiration Date, Date Last Given, or Other Info
Any Known Health problems? Explain in box below
Has your pet been given flea medication in last 30 days prior to clinic
Has your pet been given any ear mite treatment?
Has your pet been distemper vaccinated? Need date given AND expiration date
Has your pet been rabies vaccinated? We need date given and expiration date.
Has your pet bitten anyone in the last 10 days ?

Pet 1 Gender
Pet 1 Breed
Domestic Short Hair (DSH) Medium Hair (DMH) , Long Hair (DLH), Bengal, Persian, Etc.
Pet 1 Length of coat (long, medium, short)
Coat
Pet 1 Color
If any known health issues or allergies for Pet 1, please describe below:
Pet 2 Name
Pet 2 Age
Pet's Age, an approximate is OK.
Pet 2 Birthdate if under six months if known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Pet 2: Health, Vaccinations, Flea and Ear mite treatment. Please give us as much information on when treatment/vaccinations were given. Vaccine records will also need to be submitted.

Rows	Yes/No	Expiration Date, Date Last Given, or Other Info
Any Known Health problems? Explain in box below
Has your pet been given flea medication in last 30 days prior to clinic
Has your pet been given any ear mite treatment?
Has your pet been distemper vaccinated? Need date given AND expiration date
Has your pet been rabies vaccinated? We need date given and expiration date.
Has your pet bitten anyone in the last 10 days ?

Pet 2 Gender
Pet 2 Breed
Domestic Short Hair (DSH) Medium Hair (DMH) , Long Hair (DLH), Bengal, Persian, Etc.
Pet 2 Color
Pet 2 Length of coat (long, medium, short)
Coat
If any known health issues or allergies for Pet 2, please describe below:
Pet 3 Name
Pet 3 Age
Pet's Age, an approximate is OK.
Pet 3 Birthdate if under six months if known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Pet 3: Health, Vaccinations, Flea and Ear mite treatment. Please give us as much information on when treatment/vaccinations were given. Vaccine records will also need to be submitted.

Rows	Yes/No	Expiration Date, Date Last Given, or Other Info
Any Known Health problems? Explain in box below
Has your pet been given flea medication in last 30 days prior to clinic
Has your pet been given any ear mite treatment?
Has your pet been distemper vaccinated? Need date given AND expiration date
Has your pet been rabies vaccinated? We need date given and expiration date.
Has your pet bitten anyone in the last 10 days ?

Pet 3 Gender
Pet 3 Breed
Domestic Short Hair (DSH) Medium Hair (DMH) , Long Hair (DLH), Bengal, Persian, Etc.
Pet 3 Color
Pet 3 Length of coat (long, medium, short)
Coat
If any known health issues or allergies for Pet 3, please describe below:
Are you purchasing a microchip for an additional cost?
If you are purchasing a microchip, please add an email and also a secondary contact name and number (Primary contact will be on form above unless otherwise noted):
Consent for Surgery
I Understand that there are many risks involved in any veterinary surgical procedure like spay/neuter surgery and the administration of anesthesia and vaccinations, (possibly including but not limited to: flea treatment, ear mite treatment, nail trimming) including the possibility that my pet may be injured or even die as a result. I understand that despite precautions, there is a risk inherent in any medical procedure and even basic procedure can, under certain circumstances, result in injury or death. These risks have been explained to me by The Friends of the Manchester Animal Shelter and/or the veterinarian who is going to perform the surgery. They have answered any questions I had about this. After considering the risks, I give my consent to proceed with the surgery and vaccinations and hereby release the Friends of the Manchester Animal Shelter, the veterinarian performing the surgery, and all of their directors, employees, agents and volunteers from any and all claims of liability, lawsuits, or any type of other legislation related to the surgery to be performed on my pet.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I have read the consent form, fully understand it and agree to their terms (please sign with your cursor below).
Please upload any prior medical documents or the most recent vaccine certificate below.
You may take a picture with your phone or upload them from your phone or computer.
Please make sure the document is legible and has the name of the animal clearly stated.
**Rabies vaccine record must be included or we are required by law to vaccinate**
Photo of medical records
Upload Medical file or vaccine certicate

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Clinic Participant Intake and Surgical Release

Consent for Surgery