Spay / Neuter Request Form
Dog Name (Rescue Name)
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New Name
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Gender
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Please Select
Male
Female
Approx. Weight
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Age or DOB
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Breed
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Primary Color
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Owner/Foster
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Adopter or Foster Parent?
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Adopter
Foster
Owner/Foster Contact #:
*
Please enter a valid phone number.
Owner/Foster Email
*
example@example.com
Please Include any preferred days of the week or indicate any upcoming vacations or other dates to
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Have you taken your dog to your primary vet and received a rabies certificate? If you haven't, the Rabies vaccination will be administered at the time of the spay or neuter. If your dog receives a rabies vaccination at any time prior to the spay or neuter please email a copy to cherylc@716paws.org or text a copy to 716-264-0928
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Yes
No
If you have received a rabies certificate after adoption please upload a copy. If you are unable to do so please email a copy of the rabies certificate to cherylc@716paws.org or text a picture to 716-264-0928.
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As part of the procedure there are additional services that can be perform at no additional expense if needed. Please answer the following to indicate if any are needed.
Umbilical Hernias
Does your dog have an Umbilical Hernia that needs to be repaired? An umbilical hernia is an abnormal bulge that can be seen or felt at the umbilicus (belly button). If you believe they might have an umbilical hernia please text a photo to 716-264-0928
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Yes
No
Unsure
Dewclaws
Does your dog have rear dew claws that need to be removed? Most dogs have four nails on each rear foot and five on their front feet. That extra nail on the upper, inner part of a dog’s rear foot is the dewclaw.
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Yes
No
Unsure
Additional Inofrmation
Does your dog have Any ongoing medical problems of any kind?:
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Yes
No
Unknown
If yes, please provide details regarding the medical problems.
*
Is the dog on any medications not including flea, tick or heartworm preventions?
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Yes
No
If yes, Please the medications here
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Any other information pertinent to this surgery?
Below are elective options that can be added onto your service at your expense. Please select any in which you would like to have included during the procedure.
• I.V. Catheter and Surgical Fluids - $50
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I accept to have my pet get an IV Catheter and receive fluids during the procedure.
I decline to have my pet get an IV Catheter and receive fluids during the procedure.
• Bloodwork (PAP & Coag) - $68.50
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I accept to have my pet get bloodwork.
I decline to have my pet get bloodwork.
• E-Collar - $13
*
I would like to purchase an e-collar.
I decline to purchase an e-collar.
Please sign below to acknowledge your consent that the information provided is true and accurate. I understand that ALL Pets must have an e-collar (cone) when being discharged. You may bring your own and have it fitted or may purchase one from the location. 716 does not cover the cost if the incision needs to be re-closed from pet self-mutilation of the surgical site due to not wearing the e-collar.
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