EBAS SPAY/NEUTER ANESTHETIC PROCEDURE RELEASE FORM

*If you are unsure of this form and would like to discuss it with a staff member when you come in for surgery, please click the link below to bypass the release form.

https://form.jotform.com/230616437195054
ANESTHETIC PROCEDURE RELEASE FORM FOR THE EBAS FELINE SPAY NEUTER PROGRAM
Name*

First NameLast Name
Pets Name*
Date of Procedure*
BEST NUMBER TO REACH IN CASE OF EMERGENCY*
*If we cannot reach you while your pet is under anesthesia and we do not hear back from you or the appointed caretaker within 15 minutes, a professional medical decision will be made by the surgery doctor. You as the owner will be finiacially responsible for any additional charges.
CURRENT MEDICATIONS AND WHEN THEY WERE LAST GIVEN:*
IF NO CURRENT MEDICATIONS, ENTER "N/A"
FEMALES ONLY
WHEN WAS THE LAST HEAT CYCLE
WHEN WAS THE LAST PREGNANCY
Please check box below once you have read the information*

BY OPTING INTO THIS PROGRAM I UNDERSTAND I AM DECLINING CBC/CHEM LABWORK
Please check box below once you have read the information*

BY OPTING INTO THIS PROGRAM I UNDERSTAND I AM DECLINING IV CATHETERIZATION AND IV FLUIDS
Hover above each field to read additional information
RABIES - Rabies is required per TVC policy at 16 weeks of age - If proof of current rabies is not provided, vaccine one will be administered at owners expense.

Complete vaccine if due or coming dueMy pet is current/I will provide certificate if not administered at TVC
BELOW ARE ADDITIONAL SERVICES YOU MAY CHOOSE AT YOUR EXPENSE. THE EBAS SHELTER WILL NOT BE COVERING THESE ITEMS UNDER THE SPAY/NEUTER PROGRAM
FVRCP

Complete vaccine if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
FELINE LEUKEMIA (strongly recommended for outside cats)

Complete vaccine if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
FELINE LEUKEMIA TEST

Complete if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
FECAL EXAM

Complete if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
SAVE THIS LIFE MICROCHIP

I request to have a microchip implantedDecline/not interested at this timeMy pet already has a microchip
WOULD YOU LIKE A BUSTER COLLAR? $12*

YesNo
SPECIAL INSTRUCTIONS / ADDITIONAL REQUESTS
DO NOT RESUSCITATE (DNR) ORDER - (please hover over the field for additional information - click the field if filling out the form via cellular phone)*

Approve DNR - I direct Thompson Veterinary Clinic to withhold resuscitative measures from my pet in the event of cardiopulmonary arrest.Decline DNR - I direct Thompson Veterinary Clinic to perform resuscitative measures in the event of cardiopulmonary arrest.
If you answered yes to the above field, please read the below statement and sign accordingly.

I, the undersigned, being of sound mind and legal age, willfully and voluntarily make this declaration to state my desires and direct that resuscitation be withheld or withdrawn in the event of my pet listed above has cardiac or respiratory arrest. It is my intention that this order be honored by my family, my veterinarians, and all others who may partake in my pets health care.
TYPE SIGNATURE
DATE SIGNED
By typing your name below, you are also indicating you have been informed of the risks involved with anesthesia, and you have had an opportunity to discuss these risks with a veterinarian. Your signature further indicates you accept these risks and give the Thompson Vet Clinic permission to anesthetize your pet.Thompson Vet Clinic will utilize all reasonable precautions against injury, escape, or death of your pet.
TYPE SIGNATURE*
DATE SIGNED*
Hover above each field to read additional information
Should be Empty:

ANESTHETIC PROCEDURE RELEASE FORM FOR THE EBAS FELINE SPAY NEUTER PROGRAM

FEMALES ONLY