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DAH High Quality, High Volume Spay & Neuter Clinic
Canine Registration Form
18
Questions
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1
Your Name
*
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Please enter your FIRST and LAST name
First Name
Last Name
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2
Address
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Please enter a valid address.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
Phone Number
*
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Please enter a valid phone number.
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4
Can we send text messages to the provided phone number?
*
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If you select yes, you will receive text message reminders for due dates and appointment instructions. Otherwise, they will be sent via email.
Yes
No
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5
Email
*
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Please enter a valid email. Updates on your application and appointment will be sent to you via email.
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6
Pet Name
*
This field is required.
Please register ONE pet at a time.
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7
Breed
*
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8
Color
*
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9
Pet Date of Birth
*
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If unknown, please provide an estimate.
-
Month
Day
Year
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10
Pet Weight in Pounds
*
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If unknown, please provide an estimate or range.
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11
Package Selection
*
This field is required.
Please select a package. Please note that this form is for DOGS ONLY. If you are not registering a dog, please go back and select the appropriate form. Includes pre-surgical exam, spay or neuter procedure, tattoo, and pain medication to go home.
$100-$140 Canine spay (FEMALE)
$100-$110 Canine neuter (MALE)
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12
Vaccine Services
*
This field is required.
Select all that apply. Please note that if you are unable to provide proof of current vaccinations, you will be required to have these updated at the time of service at an additional cost. If your pet is not up to date on the required vaccinations (Rabies and Distemper/Da2PP/DHPP), you must select one or more of the services below.
$90 Canine Package: Rabies vaccination with tag and certificate, Distemper vaccination, Bordetella vaccination, Heartworm test and Intestinal parasite exam.
$20 Rabies vaccination (REQUIRED IF NOT UP TO DATE)
$20 Distemper vaccination (REQUIRED IF NOT UP TO DATE)
None - My pet is up to date on the required vaccinations and I have submitted proof to dahlowcostclinic@gmail.com
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13
Additional Services:
Optional additional services. If you do not wish to select any additional services, select "NEXT" below.
$12 Elizabethan collar (cone to prevent licking of incision site, HIGHLY recommended)
$40 Microchip implantation and registration
$25 Intestinal parasite exam
$20 Heartworm test
$50 Additional charge for males with an undescended testicle
$50 Umbilical hernia repair
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14
Vaccinations
*
This field is required.
Rabies and Distemper vaccinations are required to be up to date for dogs and cats. Please e-mail proof of these vaccinations to dahlowcostclinic@gmail.com prior to making your appointment. If proof of vaccination cannot be provided these vaccinations will be done at the time of the spay or neuter at your cost. If you provide proof of a previous rabies vaccination, even if it is expired, the rabies vaccination and certificate that we give will be good for 3 years. Without proof of prior vaccination the certificate will be good for one year.
I understand and agree.
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15
Vaccinations:
Please upload your pet's vaccination records here IF APPLICABLE. If you have selected vaccination services with your pet's procedure, then you do not need to provide vaccine records and can select "NEXT". Remember: Rabies and Distemper/Da2PP/DHPP are BOTH required.
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: 10.6MB
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16
Late/No Show Policy
*
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If you are more than 10 minutes late to your scheduled drop-off time or window, you will be asked to reschedule your appointment to the next available date and will be charged a $50 no-show/cancellation fee. If you do not show up for your appointment or cancel/reschedule with less than 48 hours notice, you will be charged a $50 no-show/cancellation fee. The remainder of your prepayment is non-refundable and will remain on your account to be used towards future purchases. If you are more than 10 minutes late to your assigned pick-up time, a $25 late fee will be applied to your bill. If you arrive for pick-up AFTER 5:00pm, an additional $25 late fee will be applied for a total of $50.
I understand and agree.
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17
I have read the following, understand what it says, and agree
*
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Davis Animal Hospital uses qualified staffing and approved materials for all procedures performed. It is important for you to understand that the risk of injury or death, although extremely low, is always present just as it is for humans who undergo surgery/anesthesia. Carefully read and understand the following before signing your name. I, acting as owner or agent of the pet named above, hereby request and authorize Davis Animal Hospital, through whomever veterinarians they may designate, to perform an operation for sexual sterilization regardless of sex of the animal named above on this form. I understand that the operation, use of anesthetics and drugs in providing this service, and other services provided can present some hazards and that complications, injury or death of this animal may conceivably result. I either certify that my animal has been vaccinated within one year prior to this date or waive my right to protect my animal by having it vaccinated prior to visiting the clinic. I understand that it takes up to two weeks for vaccinations to provide immunity to my animal. I understand the inherent risks of failing to maintain current vaccinations (including kennel cough) and waive all claims due to such failure. I certify that my animal is in good health and has had no food since 12:00 midnight the evening prior to surgery unless otherwise instructed. I understand that Davis Animal Hospital has the right to refuse service to any animal to whom surgery is deemed a health risk, or the animal is unable to be handled by clinic staff. I understand that Davis Animal Hospital may not perform a complete physical examination before surgery is performed. I understand that my animal will not receive preoperative bloodwork and waive my right to have this service performed at a full-service veterinarian prior to surgery. I understand that some factors significantly increase surgical risk including by not limited to pregnancy, heat cycle, obesity, brachycephalic breeds, and diseases such as Feline Immunodeficiency Virus, Feline Leukemia, and heartworms. I understand that if my animal is pregnant, the pregnancy will be terminated at surgery. I understand that if my pet is cryptorchid (having an undescended testicle) and/or has an umbilical hernia, an extra incision may be required and an additional charge applies. I understand that if fleas are found on my pet, a flea tablet will be administered at my expense (aprox. $9) I understand that my pet will have a green tattoo mark placed on the surface of its skin to designate that he/she has been spayed/neutered. I understand that I will be financially responsible for any post-operative medical treatment relating to this procedure or any other unrelated medical problems of my animal. I will hold harmless Davis Animal Hospital, its officers, directors, veterinarians, technicians, volunteers, and agents for any problems experienced by the animal as a result of the procedure or the above risk factors.
I understand and agree.
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18
Signature of Owner/Agent
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