Northeast Arkansas Humane Society | 642106 (Spay/Neuter)

Name*

First NameLast Name

Address*

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Phone Number*

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Email*

example@example.com

Pet Name*

Pet Color:

Release of Liability and Permission to Perform Vaccinations & Limited Medical Services.

The undersigned states that he or she is the owner of the animal(s) to be vaccinated. The owner agrees that or Dr. Roger McMillan and the Northeast Arkansas Humane Society, hereafter referred to as the NEAHS, are providing a service to the undersigned by providing a low-cost vaccination program. In return for this service, the undersigned agrees to hold harmless. Dr. Roger McMillan, and the NEAHS, and employees from any and all claims related to the procedure(s) performed to the animal(s) belonging to the undersigned. The undersigned also agrees, if asked to comply with the income qualifications by providing proof of government assistance or income in the form of two recent (within the last 30 days) and consecutive pay stubs. (See income guidelines) The undersigned acknowledges that the vaccines and tests may be administered by a vet tech and that we are not a full-service vet clinic, so further treatments may be needed at owner's vet at the expense of the owner.

*Payment Disclaimer: Full payment on the day of registration. I also understand if I am a no show or do not cancel 24 hours prior to my appointment I will lose my payment and unable to reschedule.*

By signing your name, you acknowledge the release of liability statement, as well as the payment disclaimer and agree to the conditions of both.*

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Does your pet require a rabies shot?*

YesNo

Clinic Service Payment*

Cat Spay ServiceFor Female Cats.

$80.00

Cat Neuter ServiceFor Male Cats

$70.00

Dog Neuter Service (50 Pounds Or Less)For Male Dogs 50 Pounds Or Less

$125.00

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Total

$0.00

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Cat /Spay Appointment

Appointment Date cat-Spay

Date

Reminder Date cat Spay

Date

Cat / Neuter Appointment

Appointment Date cat Neuter

Date

Reminder Date cat Neuter

Date

Dog / Neuter Appointment

Appointment Date Dog Neuter

Date

Reminder Date Dog Neuter

Date

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am eighteen years of age or over and authorize the veterinarian at the Northeast Arkansas Humane Society to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:• The reasonable medical and or surgical treatment options for my pet• Sufficient details of the procedures to understand what will be performed• How fully my pet will recover and how long it will take• The most common and serious complications• The length and type of follow-up care and home restraint required• The estimate of the fees for all services• Any necessary payment arrangements While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that no guarantee of warranty has been made regarding the results that may be achieved. I agree to pay a deposit of 100% of the estimated fees, assume financial responsibility for any remaining fees, and provide payment via cash or check at the time my pet is discharged from the hospital. Should any unexpected life-saving emergency care be required and the staff is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services. I have read and fully understand the terms and conditions set forth above

By signing, you acknowledge and agree to the above statement.

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Medical Services Request

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