PBSF SPAY/NEUTER FORM
Dog's Name:
Dog's Age:
Gender:
Male
Female
If female: last heat cycle:
Any chance of pregnancy?
Yes
No
Dog's Weight:
How long have you had the dog?
Can your dog be controlled on a leash?
Yes
No
Does your dog have a bite history?
Yes
No
How does your dog do with strangers?
How does your dog do around other dogs?
Are there any behavioral or other types of issues we need to be aware of?
Who is your veterinarian?
When was your dog last seen by a vet?
Has your dog had any vaccines?
Yes
No
If yes, please list the type and date received:
Is your dog on flea/tick preventative?
Yes
No
Is your dog on heartworm preventative?
Yes
No
If no, have they ever had a heartworm test?
Yes
No
Does your dog have any medical issues we need to be aware of?
Yes
No
If yes, please explain in detail:
I hereby affirm the above information is true and correct and I am the legal owner of the dog. I understand PBSF Dog Rescue will cover the cost to spay/neuter and chip my dog ONLY. Any additional medical treatment/cost will be my responsibility. I understand that there will be post-surgery restrictions for my dog and that if I do not follow said restrictions, complications are possible. Such complications are not from the surgical procedure and any treatment needed will be my responsibility. I hereby hold harmless PBSF Dog Rescue of any unexpected circumstances related to the services they are providing. Please type your name below acknowledging you have read and understand the preceding statement.
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Date
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Name:
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Email:
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