PETS Clinic Surgery Form

Appointment Date:

Date

Owner Name:

First Name Last Name

Phone Number

Area Code Phone Number

Alternate Phone Number:

Area Code Phone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Do you (or someone in your household) receive any of the following forms of assistance? (Must provide proof)

Medicaid Food Stamps CHIPS Government Housing

Pet #1 Name

Species:

Dog Cat

Sex:

Male Female

Predominant Breed:

Color(s):

Age: blanks months years

I would like my feral cat to receive an ear notch at NO charge. Owner must initial below:

Clear

It is important that our veterinarian be provided as much information as possible about your pet. Please answer the following quesitons. A minor issue to you could be very important to our vet. Please be thorough.

How long have you had your pet?

Where did you get your pet?

Please list current medications your pet is on INCLUDING flea and tick and heartworm preventatives:

Has your pet been seen by a veterinarian in the past 6 months? If yes, please explain what the visit was for. Include routine examinations:

If your pet has a current (within the year) rabies vaccine please tell us the month/year when the vaccine was received: blanks And please include the vet clinic/or veterinarian who gave the vaccine:blank Failure to provide proof of current rabies vaccine will result in your pet receiving an updated rabies vaccine at the time of surgery.

Please tell us about previous surgeries or emergencies involving your pet. Any other concerns: (breathing trouble, unexplained swelling, etc)

Pet #2 Name

Species:

Dog Cat

Sex:

Male Female

Predominant Breed:

Color(s):

Age: blanks months years

I would like my feral cat to receive an ear notch at NO charge. Owner must initial below:

Clear

It is important that our veterinarian be provided as much information as possible about your pet. Please answer the following quesitons. A minor issue to you could be very important to our vet. Please be thorough.

How long have you had your pet?

Where did you get your pet?

Please list current medications your pet is on INCLUDING flea and tick and heartworm preventatives:

Has your pet been seen by a veterinarian in the past 6 months? If yes, please explain what the visit was for. Include routine examinations:

If your pet has a current (within the year) rabies vaccine please tell us the month/year when the vaccine was received: blanks And please include the vet clinic/or veterinarian who gave the vaccine:blank Failure to provide proof of current rabies vaccine will result in your pet receiving an updated rabies vaccine at the time of surgery.

Please tell us about previous surgeries or emergencies involving your pet. Any other concerns: (breathing trouble, unexplained swelling, etc)

By signing below, I hereby agree that the highlighted procedures have been approved by me. I understand that with surgery and anesthesia there is a risk of illness and/or fatality. I accept this risk and consent to the surgical procedure for my pet. I agree to hold harmless and release from liability P.E.T.S. Clinic from any illness or fatality that results from my pet receiving the following treatment(s). To my knowledge my cat/dog is healthy and has not bitten anyone in the past 10 days. I also understand and agree that in the event I fail to pick up my pet after surgery, my pet will be turned over to the Humane Society. P.E.T.S. Clinic and HSYC are not able to board my pet. I understand my pet will receive a small green tattoo on their abdomen to indicate sterilization. Signature of Owner:

Clear