HARK spay/neuter

HARK spay/neuter
A PLACE FOR PETS AND THEIR PEOPLE

PO Box 1533, Haines AK 99827 www.harkalaska.org (907) 766-3334

Spay/Neuter Application Application must be turned into HARK- PRIOR to visiting the veterinarian. Applicant Information
Name
City
Physical address
Date

MonthDayYear
Date
State
Zip
PO box
Phone (Home)
Phone (Cell)
Email
example@example.com
Name of pet
Age
Species
Pet weight
Breeds
Gender
Current Rabies tag number
borough license number
Have you observed any of the following conditions in your pet (Please alert us prior to your appointment if any of these symptoms do arise.

vomitingdiarrheaweight lossweight gaindecreased appetiteincreased appetiteincrease thirstdecrease thirstcoughingsneezingexercise intolerancetrouble breathing
Has your pet had any major illnesses or injuries in the past (I.e., Hit by car, GI disease etc? Please explain:
Please explain
Does your pet have any chronic conditions (i.e., arthritis, thyroid disease, diabetes, allergies, seizures etc? Please explain:
Please explain
Has your pet had any anesthetic procedures in the past ie Dental cleaning surgery etc
Did your pet respond negatively to the anesthesia? Please explain
Please list any medications your pet is currently taking or has taken in the past week Please include prescribed meds, over the counter meds, supplements and preventatives
Does your pet have any known drug allergies or sensitivities Please explain
Describe your pets interactions with other pets and people ie fearful friendly etc
Is your pet known to have any degree of separation anxiety or fears? Please explain
Have you noticed any changes in your pets behavior ie reluctance to do things, aggression, changes in urination or bowel habits etc Please explain
Would you like to microchip your pet with us today
Please check any that apply to you. Are you:

Receiving Food Stamps/Medicaid/MedicareLiving in income-based housing or receiving housing assistanceA veteranApplying for a recently adopted HARK animalA current HARK member
Please initial and sign: I am the owner (or the agent for the owner) of the animal described above and I have the authority to execute this consent. I hereby consent and authorize HARK and the attending Veterinarians to perform this spay/neuter procedure. I understand that there are certain risks and complications associated with any operation or procedure of this type. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures. I hereby consent and authorize the performance of such procedures as necessary and desirable in the exercise of the veterinarian's professional judgment. I have been advised of the nature of the service and procedures, as well as the risks involved, and I also realize that results cannot be guaranteed. I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I understand there are risks associated with the use of any anesthetic or medication.
Name
Date

MonthDayYear
Date
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