Spay and Neuter Application

Missoula AdvoCats

Spay and Neuter Assistance Application

Date*

Date

Name*

Phone Number*

Address*

Alternative Phone

Animal Names*

Animal Ages*

Unsure

If Feral Cat location of colony*

Feral cats must be returned to their colony after surgery. Feral cats will have their ear clipped for identification purposes.

Not Applicable

Employer*

Spouses employer*

Combined Income*

How many dependents do you support*

Application Accepted

Application Denied

I, the undersigned, have read and understand this entire page and authorize ______________________ to anesthetize, surgically sterilize, and provide other related medical care Procedure to __________________ (Animal Name or Description dog/cat). I agree to pay according to the fee schedule set up by Missoula AdvoCats.

I understand there are medical risks associated with the Procedure, including but not limited to infection, hemorrhage, allergic reaction, anesthetic drug reaction, anesthesia-induced cardiac compromise, and death. I understand that _____________________ will perform a physical exam but not perform a comprehensive cardiac exam, other diagnostic tests, and bloodwork prior to the Procedure. I understand that there are increased risks because _____________________ will not perform extensive pre-operative diagnostic evaluations. I further understand that there are additional risks if the pet is not current on recommended vaccines.

I hold harmless ____________________, its officers, directors, veterinarians, technicians, volunteers, and agents for any problems experienced by the animal because of the Procedure or the above risk factors. I further agree to hold harmless Missoula AdvoCats that scheduled the Procedure.

If in the course of treatment a condition is discovered that requires medical attention or an additional procedure, such as hernia repair or the administration of IV fluids, the attending veterinarian may, in his/her absolute discretion, perform such procedure. I consent to these procedures and agree to pay reasonable additional charges if any.

I agree that I will be available by phone today. If a situation arises and I cannot be reached at the phone number below, I authorizeto ________________________ to use his/her discretion and clinical judgment as to how to proceed. I understand that___________________ and Missoula AdvoCats will not leave a message, and that I have to be available by phone during the day of the procedure. My phone number for today is:______________________

I agree that I will be financially responsible for any post-operative medical treatment relating to this Procedure or any other unrelated medical problems with my animal.

Signature of Client or Animal Agent*

Date*

Date

Signature of Witness*

Date*

Date