Pueblo Spay and Neuter Now Clinic Scheduling Form

Spay & Neuter Clinic Registration and Consent Form:

Fill out the form below and we will get back soon! (1) ONE appointment request and surgery release form must be completed PER pet. Clinic will be located at 270 S Purcell Blvd, Pueblo West, CO 81007, Fresh Start Environmental. Price will be $25 per dog or cat, vaccines (optional) are included in that price. Prepayment due in full at booking!
Client Name*
Provide your first and last name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email Address for Appointment Confirmation & Reminders (Required)*
example@gmail.com
Pet's Name - Separate Form Must Be Completed for Each Pet*
This registration form is for one dog only - list only one name for registration to be accepted
Gender:*

FemaleMale
Species:*

DogCat
Pets over 5 years old will require veterinary team approval to book.

Please provide your pets age in years and months below:
Age in Years?*
Whole numbers only, put “0” if under a year old
Age in Months?*
Whole numbers only
Dog Breed(s):*
Provide your best guess if unknown
Cat Hair Length/Breed - Select “Other” & Type Breed if Purebred:*

Domestic Short HairDomestic Medium HairDomestic Long HairOther
Common Dog Breeds with MDR1 Mutation (Anesthesia/Spay/Neuter Surgery Risk):

Collie (Rough and Smooth)
Australian Shepherd (Standard and Miniature)
Border Collie
Shetland Sheepdog (Sheltie)
Old English Sheepdog
German Shepherd
Herding Breed Mixes (due to the prevalence in herding breeds)

Anesthesia Risks for MDR1 Mutation Carriers: Increased Sensitivity to Certain Anesthetic Agents: Can lead to prolonged recovery times or increased risk of complications during and after anesthesia-related procedures such as spaying or neutering.
I understand that additional anesthesia risks apply if my dog happens to carry the MDR1 mutation. I confirm understanding that no pre-surgical labs will be conducted by Pueblo Spay and Neuter Now to determine the presence of this mutation.*

YesNo
I understand that surgery poses additional risks for brachycephalic breeds - dogs with short noses and flat faces, such as Bulldogs, Pugs, and Boston Terriers - due to their unique physiological characteristics. These additional risks include: Breathing Difficulties, Heat Regulation Issues, and Anesthetic Sensitivity: Due to their distinctive respiratory system and potential heart issues, I understand brachycephalic dogs may react differently to anesthesia.*

YesNo
I understand that surgery poses an additional risk for dogs with Von Willebrand’s disease - a genetic bleeding disorder where blood doesn’t clot properly, increasing the risk of excessive bleeding during surgery. Breeds commonly affected include Doberman Pinscher, Shetland Sheepdog, Golden Retriever, Standard Poodle, and Scottish Terrier. I certify my understanding an additional risk of excessive bleeding applies if my dog happens to have Von Willebrand’s disease:*

YesNo
List any known behavior issues, aggression towards people or animals, medical history, health concerns or medications your pet is currently taking.
If known, please list any current vaccinations your pet has, include type of shot and date given
SELECT YOUR PET’S WEIGHT RANGE (BEST GUESS IF UNKNOWN): this will determine drop off time day of surgery. Regardless of the exact time selected below, you may still arrive any time within the windows indicated below. If you are bringing dogs in more than one weight class, drop off with the largest dog in the group.*

Up to 25 pounds = 9:30-10:30am drop off26-50 pounds = 8:45-9:30am drop off51-75 pounds = 8:00-8:45am drop off76 pounds or over = 7:30-8:00am drop off
ENTER ALL INFO ABOVE FIRST: IF NO APPOINTMENTS ARE DISPLAYED BELOW THEN THEY HAVE BEEN BOOKED FOR YOUR PET’S TYPE, SIZE, AND/OR GENDER

If you are on the waitlist you will be notified of the next clinic when registration opens.You will continue to receive notifications about upcoming clinics until you request otherwise. Email info@pueblospayandneuternow.org for information on alternative clinics and resources.
SMALL DOG FEMALE Appointment Date Selection: Drop Off Time Varies by Weight Class as Displayed in Field Above *
SMALL DOG MALE Appointment Date Selection: Drop Off Time Varies by Weight Class as Displayed in Field Above *
SMALL-MEDIUM DOG FEMALE Appointment Date Selection: Drop Off Time Varies by Weight Class!*
SMALL-MEDIUM DOG MALE Appointment Date Selection: Drop Off Time Varies by Weight Class!*
MEDIUM-LARGE DOG FEMALE Appointment Date Selection: Drop Off Time Varies by Weight Class!*
MEDIUM-LARGE DOG MALE Appointment Date Selection: Drop Off Time Varies by Weight Class!*
LARGE DOG FEMALE Appointment Date Selection: Drop Off Time Varies by Weight Class!*
LARGE DOG MALE Appointment Date Selection: Drop Off Time Varies by Weight Class!*
CAT APPOINTMENTS - All Sizes & Genders*
Select any additional services you would like your pet to receive on the day of surgery:

Rabies (pet must be 16 weeks old or older):$0 FREEFVRCP (cats only): $0 Free(DHPP/DHLPP) Canine Distemper Combo (dogs only): $0 FREEMicrochip: $10 (CASH ONLY AT CHECK IN)Ear Tip (Feral/Colony Cats): $0 FREE
Consent to Tip Ears: Owner/Caregiver your initials are required to authorize removal of the top quarter of the cat's left ear. Initialing below also certifies your understanding that this is a permanent alteration to this cat's appearance *
What is your household’s annual income (we use this information for grants & reporting only):*

Up to $20,000$20,000-$40,000$40,000-$70,000$70,000-$100,000Over $100,000
Please indicate how many people live in your household (information used for grants and reporting only):*
Children and Adults
Please indicate how many children and dependents live in your home (information used for grants and reporting only): *
Children & Non-Working Adults
Does anyone in your household receive public assistance benefits, like Medicaid or Food Stamps (information used grants and reporting only):*

YesNo
In the event of an emergency, do you want our veterinarian to perform CPR on your pet?*

YesNo
By signing this form I authorize Pueblo Spay and Neuter Now to perform surgery on my pet. I understand that risk exists with any surgery, and that the specific risks associated with spay and neuter surgery will be explained to me at check-in. I release Pueblo Spay and Neuter Now, along with any of their affiliates, volunteers, or veterinary partners, of any financial or legal liability associated with the inherent risks of anesthesia/surgery. I certify that I, the undersigned Owner, or Agent of the owner, of the pet identified above, certify that I am eighteen years of age or over and I authorize the veterinarian(s) of Pueblo Spay and Neuter Now to perform the above procedure(s). I understand that the terms “spay” and “neuter” are used to indicate surgical sterilization of a pet to prevent breeding and birth of puppies/kittens. I accept my pet will receive a small tattoo to show they have been sterilized. I hereby release the veterinarians, agents and representatives of Pueblo Spay and Neuter Now from any and all liability that might arise from surgery on the above named animal including but not limited to injury, escape or death. By signing, I confirm my understanding that older, pregnant or “in-heat” animals pose a potential risk for complications and that surgery will be performed only at the discretion of the attending veterinarian. I understand that Pueblo Spay and Neuter Now, and the veterinarian have the right to refuse service to any animal when surgery is considered to be an unacceptable risk. I certify my understanding that I am encouraged to discuss those risks prior to signing this form. I understand that my animal may not receive a complete physical exam prior to surgery. I agree that if I fail to retrieve my animal(s) by the end of the day of surgery, or by some other previously agreed upon time, Pueblo Spay and Neuter Now has the right to assume ownership of my animal. I acknowledge that home care instructions have been provided to me via email, and I have been given an opportunity to view this video and have my questions answered to ensure understanding. I will also receive a printed copy of surgery aftercare instructions at check out. Upon the post-operative release of my animal. I hereby consent to Pueblo Spay & Neuter Now using photographs of my animal for networking, advertising or teaching purposes. I have read and fully understand the terms and conditions set forth above. My signature on this form indicates that any questions I have regarding my pet’s surgery have been answered to my satisfaction. I am to contact my primary veterinarian or a local ER veterinarian in the instance any issues/reactions arise. Questions regarding this consent form or post-operative care can be directed to info@pueblospayandneuternow.org. *

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$25 minimum payment required to book. If you would like to make a donation, please enter an amount over $25 (for example: type $30 to donate $5)*

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USDPrepayment required to book appointment: $25 per cat or dog.

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

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Spay & Neuter Clinic Registration and Consent Form:

Pets over 5 years old will require veterinary team approval to book.

ENTER ALL INFO ABOVE FIRST: IF NO APPOINTMENTS ARE DISPLAYED BELOW THEN THEY HAVE BEEN BOOKED FOR YOUR PET’S TYPE, SIZE, AND/OR GENDER