Dog Spay/Neuter Surgical Consent Form

DUE TO THE INCREASINGLY HIGH FEES FOR CREDIT OR DEBIT CARD PROCESSING, WE KINDLY ASK THAT YOU PAY IN CASH IF POSSIBLE. THANK YOU FOR UNDERSTANDING! (online deposit must be paid with a card)

The Watertown Humane Society Spay-Neuter Clinic provides a lower cost spay/neuter option for pets owned by the community as well as animals who are part of rescue organizations.

Our clinic has now moved back to our permanent location:

418 Water Tower Court - Watertown

Drop off time for surgery is between 8:00am and 8:30am and pick up time will be communicated on surgery day. Please keep in mind unpredicatable things can happen on surgery day so we may run late, please do not show up to pick up your pet until you have been called.

Spay/neuter surgery carries a one-time cost that is relatively small compared to the long-term benefits. Along with helping curb pet overpopulation, spay/neuter surgery allows pets to live longer, healthier lives. It also makes them less likely to spray and/or mark territory and eliminates heat cycles. Unsterilized animals often exhibit more behavior and temperament problems than those who have been spayed or neutered.

Please fill out a SEPERATE form for each pet you would like to be seen in our Spay/Neuter Clinic.

* Please note, a current rabies vaccination certificate is required for animals undergoing procedures at the WHS Spay-Neuter clinic. If your animal does not have a current rabies vaccination you will be required to purchase one at your appointment.

Full Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone*

Email*

Dog Name*

Age (approximate if unknown. Animals under 6 months of age do not need to be fasted prior to surgery but no food the morning of. All other ages should be fasted after 9pm the night before surgery. Water is ok for all.)*

Animal's Age above is in Months or Years?*

MonthsYears

Estimated Weight (please note, there is an additional $50 charge for dogs over 75 pounds.*

I agree to pay an additional $50 if my dog weighs more than 75 pounds*

YesNo

Sex*

MaleFemale

Color*

Breed (if unknown, enter "mixed breed")*

Has your animal experienced vomiting or diarrhea in the past 10 days?*

YesNo

Has your dog bitten anyone in the past 10 days?*

YesNo

Has your animal gone under anesthesia in the past and experienced any difficulties?*

YesNoUnknown

If yes, please explain:

Is your animal on any medications?*

YesNo

If yes, please list medications and dosage:

Any previous vaccine reactions or allergies?*

YesNoUnknown

If yes, please explain:

Are you aware we are located in WATERTOWN WISCONSIN? This deposit is NON-REFUNDABLE!*

YesNo

I agree to pay a $300 fee for a Canine Neuter/Spay (Deposit deducted from final cost)*

YesNo

I agree to pay a $350 fee for a Canine Neuter/Spay if my dog weighs more than 75 pounds. (Deposit deducted from final cost)*

YesNo

I request sedation medication to keep my pet calm after surgery. (Gabapentin and Trazadone) $15 FEE*

YesNo

I agree to pay a $15 Fee for sedation meds if the vet requires them to keep my pet calm after surgery. (Gabapentin and Trazadone)*

YesNo

My pet's rabies vaccine is current*

YesNo

All pets must be current on their Rabies Vaccine. I agree that my pet will be given a rabies vaccine and I will be charged the $20 Fee if proof of current status is not shown*

Yes

3 Year Rabies (proof of current rabies status required) $25 Fee*

YesNo

I understand that if my animal is discovered to have live fleas a Capstar will be administered and I will be charged $10*

Yes

I understand that if my animal is discovered to have an umbilical hernia or be a crypt orchid (undescended testicle) it will be corrected and I will be charged $25 (per need)*

Yes

I would like my pet to receive the DHAPP vaccine (Distemper) $20 Fee*

YesNo

I would like my pet to recieve the Bordatella Vaccine (Kennel Cough) $20 Fee*

YesNo

I would like my pet to receive the 4DX Heartworm Test $35 Fee*

YesNo

I would like my pet to receive Flea/Worm Treatment (generic form of Revolution-active ingredient Seleamectin) $15 Fee*

YesNo

I would like to bring in a stool sample for fecal test $50 Fee*

YesNo

I would like my pet to receive a Microchip $20 Fee*

YesNo

I understand that underlying conditions may exist without anyone knowing about it and may not be observable during the brief pre-surgical exam.*

I agree

I understand and agree to the information stated about regarding surgical risks*

I agree

I understand and agree to use an e-collar on my dog for 10-14 days following surgery*

I agree

I, being lawfully authorized to make decisions on behalf of the animal named/described above (the "Animal"), hereby request and authorize WHS, including its affiliates and each of their employees, volunteers,veterinarians and/or other agents (collectively,"WHS Parties") to recieve, transport, prescribe for, treat and/or administer vaccinations and/or perform an operation on the Animal.*

I agree

I certify that the Animal has not bitten anyone in the last ten (10) days.*

I agree

I understand that the operation I have elected presents some hazards, and that injury to, post-operative infection in, or death of, the Animal may conceivably result, for there is some inherent risk in the procedure and in the use of anesthetics and drugs provided for the procedure, as well as in any vaccines used. I understand general anesthesia will be administered to the Animal for surgery. I understand and accept these risks to the Animal.*

I agree

I understand the inherent risks of failing to maintain current vaccinations and waive all claims arising out of, or connected with, the performance of this operation due to such failure. I understand, in particular, that if the Animal develops kennel cough or other upper respiratory infections after surgery, I am responsible for treatment at my own cost.*

I agree

I understand that WHS and/or any WHS party has the right to refuse any service and/or procedure to any animal for any reason, including, but not limited to, situations where surgery is deemed a health or safety risk. Such refusal is at the sole discretion of the attending veterinarian.*

I agree

I understand that a pre-surgerical exam will be performed on the Animal when possible, but that there are times, in the attending veterinarian's sole discretion, when such an exam may only be performed after the Animal has already been sedated or anesthetized. I understand that the Animal will not receive pre-operative bloodwork at WHS. If I choose for the Animal to have such bloodwork, I understand that it must be performed at a full service veterinary clinic.*

I agree

I understand that some risk factors significantly increase surgical risk, including, but not limited to, pregnancy, heat, and diseases such as heartworms, obesity, blood clotting disorders, endocrine diseases, and senior animals.*

I agree

If an unforeseen event/emergency situation occurs or a medical condition is discovered that requires urgent immediate medical treatment, I consent that the attending veterinarian may perorm such treatment, or transport the Animal to another veterinarian for the provision of such treatment at my expense, without seeking additional authorization or consent from me.*

I agree

I understand that my further consent will be required for non-emergency treatment EXCEPT in cases where the Animal has an open umbilical hernia, which may be repaired at the time of surgery at an additional charge of $25 without my further consent, and/or agree that if one or more of my male animal's testicles are not descended (cryptorchid) I will be charged $25-$50 per undescended testicle, depending on location. This will be due at the time of pick up.*

I agree

I understand that if I do not show proof of a current rabies vaccination, WHS will automatically administer a one year rabies vaccine to my animal.*

I agree

Surgery drop off is between 8-8:30am and pick up time will be communicated when I drop off. An additional $15 charge will be applied if picking up tardy.*

I agree

All pets must be leashed or in a carrier.*

I agree

All animals will receive a small tattoo on his/her underside to show that they have been sterilized.*

I agree

Surgery/Anesthesia:
Your dog has been through major surgery. He/she will need special attention for a full, uneventful recovery, just as a human would. Please read and review the following instructions. If you have any questions at any time, please call the shelter at 920-261-1270.

Activity:
Your dog will need to wear an e-collar for 10-14 days following surgery. Please bring one along with you when you pick up or your pet or be prepared to purchase one for $15 at the shelter during pick up. E-collars are required. No exceptions. No free running (must be on a leash) or jumping for 10-14 days. This includes outside time for going to the bathroom. No bathing or swimming for a minimum of 14 days after surgery.

If your pet is an outdoor dog, please make arrangements to keep him/her in an indoor area until he/she is fully healed.

Diet:
You can resume normal diet tonight, but at a reduced amount. Begin by offering a small amount of water when you get home. Then you can offer him/her a small amount of food. Avoid offering too much food too quickly, as this may cause vomiting.

Medications:
Begin all medications on the day of discharge unless otherwise directed. Directions for medications are printed on each bottle. Please observe recommendations for giving with food if stated.

Incision Care:
Please check the incision daily. Some redness and swelling is a normal consequence of surgery and healing. If the incision becomes painful, opens or dishcarges pus or blood, please contact your regular veterinarian for follow up care. A small amount of clear fluid may ooze from the incision and is considered normal. DO NOT allow your dog to lick, chew, rub or pull at the incision. E-collars MUST be worn for the 10-14 days following surgery.

I understand and agree to follow the discharge instructions below to the best of my ability*

I agree

I understand the importance of keeping my pet's incision site dry and clean for the 14 days following surgery*

I agree

I understand that if my dog is attempting to chew, lick, or bite the incision, I will do whatever is necessary to prevent that behavior*

I agree

I understand that there are risks involved in any surgery and I will not hold the Watertown Humane Society responsible for any unforeseen complications*

I agree

I understand that if any complications from the surgery arise I am to contact my local veterinarian for care for my pet*

I agree

I understand that if my regular veterinarian is not able to see my pet, I will take my pet to the soonest available emergency veterinarian clinic*

I agree

I have reviewed the charges associated with the spay/neuter surgery and any additional medical care I wish to have performed and agree to pay in full (minus the deposit paid) at pick up*

I agree

Signature (please use your finger if using a smart phone or mouse if using a computer to electronically sign:*

Dog Spay/Neuter Surgical Consent Form

Applicant Information

Dog Information

Optional Additional Medical Consent

Pre Surgical AGREEMENT

Dog Take Home Instructions

Post Surgical AGREEMENT