Smith Veterinary Hospital

Frozen Canine Semen Release Form

This form must be completed by the semen owner and submitted before frozen semen can be released. This form is not a transfer of ownership. Please submit this form to arrive at least 3 business days before the requested shipping date. Smith Vet will confirm receipt of the form by email or phone; if you have not received a confirmation, please resend the form. It may not be possible to ship frozen semen if this form is received too late. THIS FORM WILL EXPIRE 90 DAYS

FROM THE DATE LISTED BY THE SIGNATURE OF OWNER BELOW. IF NO ACCURATE DATE IS LISTED BY THE SIGNATURE BELOW, SMITH VET WILL FILL IN THE DATE. THIS IS A 2 PAGE FORM; BOTH PAGES REQUIRE SIGNATURE PRIOR TO SHIPMENT.

Registered Name of Dog Breed Registry and Number

Please circle the NUMBER OF BREEDINGS TO RELEASE: ONE TWO THREE OTHER

Preferred Date of Semen Shipment to Arrive On or Before:

IF A DATE IS UNKNOWN AT THE TIME OF SUBMITING

THIS FORM, PLEASE ENTER "WILL CALL" FOR THE DATE OF SHIPMENT.

This shipment will be insured by the shipper to cover the shipping tank replacement in the event of damage/loss during shipping. Additional insurance to cover the value of the semen may be purchased at the carrier's rate (usually UPS, FedEx, or Air Cargo), however, many carriers will not insure perishable goods, so insurance may not cover loss of the items shipped, if this occurs. If you wish to insure the contents, please indicate the amount, knowing the carrier may not

frozen sperm cells are viable or will remain viable at the time of, or after, the cells are frozen. In the event of loss or damage of frozen semen due to natural causes due to weather, fire, storage/shipping tank failure, or shipping accident/damage, Smith Vet will not be held liable for the loss or the replacement value of the frozen semen. Shipping costs can be paid by another person, however, the semen owner is ultimately responsible for all costs. Any chargebacks by the payment information provided will be reimbursed to Smith Vet by the semen owner. The semen owner is responsible for informing the payer of the fees involved in shipping and preparing frozen semen from their account. Frozen semen shipments are not completed until the shipping tank is returned undamaged to our office. Please complete and return this form to FAX: 260.589.2087 OR E-mail: smithvet@adamswells.com. Postal service is not recommended and may delay the shipment. Smith vet policy is to provide use of the shipping tank for domestic shipments for 7 days at a charge of $75. On the eighth day, a daily rental of $20.00 applies until the shipping tank is returned, or until the replacement cost is reached.

Use of Frozen Canine Semen Release Forms older than this current version (11/2021) are not acceptable. Prices are subject to change without notice.

By my signature below, I agree to all statements made in this Frozen Canine Semen Release Form:

PROCEDURES FOR UTILIZING YOUR STUD DOGS FROZEN SEMEN

When you wish to utilize the frozen semen you have stored here, the following steps should be followed in order to ensure that shipping and artificial insemination are carried out efficiently:

1. Ensure your account balance is zero. If you have any questions about your account, please call 260.589.2460

2. Notify the office early in the bitch's estrous cycle. For example, on the first or second day that you notice a red vaginal discharge from the bitch, send us a completed Frozen Canine Semen Release Form.

3. Allow 3 to 4 days for shipment of the frozen semen. Usually, we can ship sooner than this; however, allow a safe margin of time for the shipment to be handled.

It is impossible, to ship with just one days' notice before a bitch needs to be bred, or on a holiday or weekend. A 24-hour period of time is required to charge the shipping tank prior to retrieval of the frozen semen and transfer to the shipping tank.

4. When you request Smith Vet to ship your dog's frozen semen, please be sure you complete this form, listing the name, address, and telephone number of the shipment destination. Specify how many breedings of semen to release for shipment. In most cases, 1 or 2 breedings are shipped. We accept Visa, MasterCard, Discover, or American Express for the shipping charges, and usually the bitch owner will pay for the preparation and shipping of the frozen semen. In some instances cash, cashier's check, or a money order may be required for pickup of frozen semen. Please note that Smith Vet cannot release frozen semen without the completed Frozen Canine Semen Release Form. Please note a completed

Frozen Canine Release Form is not a Transfer of Ownership.

5. Smith Vet will arrange for the shipping of your dog's frozen semen.

6. Shipping charges, tank rental, and return are ultimately the responsibility of the semen owner. It is often very expensive to ship frozen canine semen; if cost is a concern, please call for a shipping estimate. We are happy to provide an approximate quote for shipping. At this time, we ship the frozen semen via FedEx. For domestic shipping, there is a tank rental charge of $75. On the 8th day, a daily tank rental fee of $20 is charged until the tank is returned or until the replacement cost of the tank is reached.

We recommend for the semen owner to emphasize the rental fee to the recipient, and that it is necessary for the bitch owner or veterinarian at the bitch's location to return the shipping container as quickly as possible to avoid additional rental charges.

7. In the event of loss or damage of frozen semen due to weather, fire, storage/shipping tank failure, or shipping accident/damage, Smith Vet will not be held liable for the loss or the replacement value of the frozen semen. Prices subject to change without notice.

8. Sperm cells will eventually cease living, but no one knows or can predict when this will occur, and it can vary from dog to dog. Smith Vet shall not be held liable for, and cannot guarantee conception from, frozen canine semen. Nor can Smith Vet guarantee that the frozen sperm cells will be viable at the time of thawing for insemination. Smith Vet is not responsible for differences in thaw rate and quality of sample as determined by inseminator.

9. Smith Vet cannot be held liable for any damages to semen once the semen is released from Smith Vet.

In any event, Smith Vet's liability, as well as that of any of its principals, employees or agents, if determined, shall not exceed the total compensation received by Smith Vet under this agreement. This limitation of liability applies for any and all claims, losses, expenses, injuries or damages, arising out of or in any way related to the performance of this agreement by reason of any act or omission, including breach of contract, negligence, errors, omissions, strict liability, breach of warranty or any reason whatsoever, not amounting to a willful, wanton or intentional wrong. This limitation of liability includes, but is not limited to claims for lost profits, loss of use, costs of replacement special damages and/or indirect or consequential damages whatsoever, caused by Smith Vet, its principals, employees or agents. In the event that any dispute arises between the parties to this agreement, you agree that the dispute shall be governed by laws of the State of Indiana, USA, without regard to any conflict of law provisions and you agree to the exclusive personal jurisdiction and venue in the state and federal courts located in City of Berne, In, USA. In the event of any lawsuit or claim being made to enforce the terms of this agreement, the prevailing party in such lawsuit or claim shall be entitled to an award of their reasonable attorney fees and costs.

By my signature below, I authorize Smith Veterinary Hospital to perform services for me. I agree to all statements made in this document preceding my signature below. I understand Smith Vet does not guarantee fertility or successful fertilization. I also understand Smith Vet is not responsible for services rendered by non-Smith Vet individuals or entities. My payment for services is due at the time of the service. Other charges may be applied to my provided payment information at a later date, if additional services are necessary. SMITH VET may or may not notify me of these additional charges prior to charging my provided payment information. I agree to any fees Smith Vet charges to my provided payment information to be made without informing me. I further state that Smith Vet has offered to provide an

estimate of these charges to me. In the event that I initiate a chargeback, or a check bounced, I understand I willbe

charged additional fees. If Smith Vet has to prove in any way that I authorized the use of my provided payment

information, I will incur additional fees from Smith Vet any time they are required to prepare a response to my chargeback. I also agree that any person I allow to access my frozen semen at Smith Vet, or any person that pays fees billed to my account at Smith Vet will be guaranteed by me. Any person I ask Smith Vet to bill on my behalf will be informed by myself of fees or charges made by Smith Vet. If the person reverses any charge at Smith Vet, I will be held liable for reimbursement to Smith Vet immediately. It is my responsibility to ensure Smith Vet is paid for all services performed by or charged through Smith Vet to my account.