Feline Neuter Estimate and Surgery Authorization Form

Hometown's Helping Hand

Discounted Feline Neuter Estimate and Surgery Authorization Form
Client Information
Date of Surgery or Today's Date if you do not have a surgery date assigned at this time.

MonthDayYear
Date
Are you a new client?*

YesNo
Name*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Number you would like us to contact you the day of surgery, if there is any question or if an emergency.*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Spouse
Spouse's Phone Number

Area CodePhone Number
Please fill out the information below if you are planning on writing a check. Driver's License or Social Security Number
Driver's License Number
Driver's License Expiration Date

MonthDayYear
Date
Social Security Number
How did you become aware of Hometown Veterinary Services?*

Drive ByNewspaperInternetFacebookReferral
Name of person who referred you:
Pet Information
Is this the first time this pet has been seen at Hometown?*

YesNo
Name of Pet*
Breed*

Domestic Short HairDomestic Long HairOther
Color (s)*
Approximate date of birth*

MonthDayYear
Date
Feline Neuter Estimate
Please check all the boxes below of the services you are authorizing.

All Items that say "FREE" are included in surgery automatically.

Please note that all additional items are at a discounted price and only good for the day of surgery.
My Products*
prevnext( X )
Feline Neuter $126.00
Feline Neuter prior to discount: $168.00

Quantity
Item subtotal:$0.00

25 % Off Feline Neuter$ Free
25% Discount of $42.00 is already taken out of above Neuter

Pre Surgery Physical Exam$45.00
*If your pet has been seen by the doctor in the last 12 months, this charge will be taken off.

Metacam Injection (Pain Medication)$ Free
Included in surgery package

Surgical Prep/Pack$ Free
Included in surgery package

Anesthetic during surgery$ Free
Included in surgery package

Hospital care during/after surgery$ Free
Included in surgery package

Complimentary nail trim with surgery$ Free
Included in surgery package

Pre-Anesthetic Bloodwork (Profile 1) (0-2 years of age)$89.00
Healthy patients under 2 years of age. BUN/CREATININE (Kidney), ALKP/ALT (Liver), GLUCOSE (Sugar), TP (Hydration)

Pre-Anesthetic Bloodwork (Profile 2) (2-7 years of age)$112.00
Healthy patients 2-7 years of age.Includes ALL of the enzymes being checked in Profile #1 PLUS a CBC (Complete Blood Count)

E-Collar$10.00

2-Day Antibiotic Injection$20.00

14-Day Antibiotic Injection$42.50

Feline Leukemia/FIV Test$55.00

Rabies Vaccine$25.50

Feline FVRCP Annual Vaccination$25.50
This protects against several viral diseases, which are: Feline Herpes virus, Feline Rhinotracheitis, and Feline Calici virus which are all major causes of upper respiratory infections. This also protects against Feline Panleukopenia which is a highly contagious gastrointestinal disease that supresses the immune system.

Feline Leukemia Virus Vaccine (FELV)$38.00
Protects against a contagious and life-long virus. This is often spread from cat-cat via saliva and nasal secretions, and causes a deficiency in the immune system.

Microchip$48.50

Ear Cleaning$22.00

Nexgard Combo$28.00
1 month De-wormer and Flea Prevention

Total $0.00
How would you like to pay:

Text To Pay - secured link prior to you picking up your petManually give technician your credit card when you pick up your petManually give technician cash or check when you pick up your pet
Pre-Anesthetic Bloodwork

Please read carefully and sign:
I understand that by not checking the appropriate box and associated charge for Pre-anesthetic bloodwork in the estimate above, lab-work or bloodwork will not performed prior to my pet's procedure. Please sign below
Authorization To Perform Surgery

Please read carefully and sign:
I hereby authorize the admitting veterinarian to administer such treatment(s) as is necessary to perform the above-mentioned surgery as well as additional services.

I understand that there may be a risk involved in these procedures. I consent to the administration of such anesthetic as are necessary.

Anesthetic Risks: (Although every effort is made to make anesthesia as safe as possible including vital sign monitory and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks). The incidence of complications from anesthesia is extremely low and we do not anticipate any in your pet, but on rare occasion the following can occur: 1) Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occations, general anesthesia can result in death.
Today's Date*

MonthDayYear
Signature*
Should be Empty:

Hometown's Helping Hand

Client Information

Pet Information

Feline Neuter Estimate

Pre-Anesthetic Bloodwork

Authorization To Perform Surgery