Feline Spay Estimate and Surgery Authorization Form

Hometown's Helping Hand

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

MonthDayYear
Date
Client Information
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
Would you like to have your cat front de-clawed?*

YesNo
Feline Spay 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 Spay$167.00

Quantity
Item subtotal:$0.00

25 % Off Feline Spay$-41.75
Hometown's Helping Hands Spay and Neuter Discount

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

Wellness Exam Pre Surgery$ Free

Profile 1 Bloodwork$72.00
Healthy patients under 2 years of age. BUN/CREATININE (Kidney), ALKP/ALT (Liver), GLUCOSE (Sugar), TP (Hydration)

Profile 2 Bloodwork$109.50
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$12.50

14-Day Antibiotic Injection$30.00

Feline Leukemia/FIV Test$45.00

Rabies Vaccine$17.50

Rhinotracheitis, Calicivirus, Distemper Vaccine (RCD)$17.50

Feline Leukemia Virus Vaccine (FELV)$29.00

Microchip$45.00
*Discounted day of Surgery

Ear Cleaning$15.00

Nexgard Combo$25.00
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-Surgery Blood Work Authorization

Please Sign Below
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:

Clear
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 procedurres. 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 anethesia can result in death.
Today's Date*

MonthDayYear
Signature*

Clear
Should be Empty:

Hometown's Helping Hand

Client Information

Pet Information

Feline Spay Estimate

Pre-Surgery Blood Work Authorization

Authorization To Perform Surgery