HAINES ANIMAL RESCUE KENNEL

HAINES ANIMAL RESCUE KENNEL
A PLACE FOR PETS AND THEIR PEOPLE

www.harkalaska.org I (907) 766-3334

Spay/Neuter Application Application must be submited to HARK- PRIOR to visiting the veterinarian.

Applicant Information
Name
Date

MonthDayYear
Date
Physical address
PO box
City
State
Zip
Phone (H)
Phone (C)
Email
example@example.com
Pet Information
Name of pet
Species
Age
Breed(s)
Gender
Pet weight
Current Rabies?
Licensed?
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 appetiteincreased thirstincreased urinationcoughingsneezingexercise intolerancetrouble breathing
Has your pet had any major illnesses or injuries in the past (I.e., Hit by car, GI disease etc.)? Y/N
Please explain:
Does your pet have any chronic conditions (i.e., arthritis, thyroid disease, diabetes, allergies, seizures etc.)? Y/N
Please explain:
Has your pet had any anesthetic procedures in the past? (i.e., Dental cleaning, surgeries, etc.)? Y/N
Did your pet respond negatively to the anesthesia? Y/N
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? Y/N
Please explain
Describe your pet's interactions with other pets and people (i.e., fearful, friendly, etc.)
Is your pet known to have any degree of separation anxiety or fears? Y/N
Please explain:
Have you noticed any changes in your pet's behavior (i.e., reluctance to do things, aggression, changes in urination or bowel habits etc.)? Y/N
Please explain:
Would you like to microchip your pet with us today? Y/N
Please check all that apply to you. Are you:

Receiving Food Stamps/Medicade/MedicareLiving in income-based housing or receiving housing assistanceA veteranApplying for a recently adopted HARK petA 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.
Signature

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