Dog Spay/Neuter Surgical Consent Form

SPECIAL SURGICAL REQUEST FORM
PLEASE NOTE, WE ARE NOT AN EMERGENCY VET CLINIC. OUR CLINIC IS OPEN TUESDAYS, WEDNESDAYS, AND THURSDAYS. CASES WILL BE LOOKED AT ON A CASE BY CASE BASIS TO DETERMINE IF THE SERVICES REQUESTED CAN BE PERFORMED BY OUR TEAM WITH THE RESCOURCES AVAILABLE TO US.

WE WILL DO OUR BEST TO OFFER COST SAVING SERVICES WHENEVER POSSIBLE.

Our clinic has now moved back to our permanent location:

418 Water Tower Court - Watertown

Please fill out a SEPERATE form for each pet you would like to be seen in our Spay/Neuter Clinic.
Applicant Information
THIS FORM IS NOT FOR SPAY/NEUTER REQUESTS - PLEASE FILL OUT THE CORRECT FORM FOR THESE SERVICES ON OUR WEBSITE*

I understand
Full Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone*
Email*
By submitting your phone number, you agree to receiving texts from Watertown Humane Society.*

I agree
Pet Information
Pet Name*
Species*

DogCatOther
Age (approximate if unknown)*
Animal's Age above is in Months or Years?*

MonthsYears
Estimated Weight *
Sex*

MaleFemale
Color*
Breed (if unknown, enter "mixed breed")*
Has your animal experienced vomiting or diarrhea in the past 10 days?*

YesNo
Has your animal bitten anyone in the past 10 days?*

YesNo
Has your animal gone under anesthesia in the past and experienced any difficulties?*

YesNoUnknown
If yes, please explain:
Is your animal on any medications?*

YesNo
If yes, please list medications and dosage:
Any previous vaccine reactions or allergies?*

YesNoUnknown
If yes, please explain:
Special Service Requested

Please select the service you are requesting to be performed. Please choose at least one.
I UNDERSTAND THIS FORM IS NOT TO BE USED FOR SPAY/NEUTER REQUESTS. YOU CAN FIND THAT FORM ON OUR WEBSITE.

I AGREE
Abdominal Exploratory Surgery (Foreign Body Removal or Biopsies)Amputation (Digit, Ear, Tail, Leg)C-SectionCystotomyDental Cleaning/ExtractionsEntropion RepairEnucleationHernia RepairMass RemovalPyometraSplenectomyVulvoplastyOther
Please provide any information that would help determine if we can help. *
All pets must be current on Rabies Vaccine. I agree that my pet will be given a rabies vaccine and I will be charged the $20 Fee if proof of current status is not shown*

Yes
I would like my pet to receive a 3 Year Rabies (proof of current rabies status required) $25 Fee*

YesNo
I would like my pet to receive the DHAPP vaccine (Distemper) $20 Fee*

YesNo
I would like my pet to receive the Bordatella vaccine (Kennel Cough) $20 Fee*

YesNo
I would like my pet to receive a 4DX Heartworm Test $35 fee for dogs $25 fee for cats*

YesNo
I would like my pet to receive Flea/Worm Treatment (generic form of Revolution-active ingredient Seleamectin) $15 Fee*

YesNo
I would like to bring in a stool sample for fecal test (includes Giardia screening $50 Fee*

YesNo
I would like my pet to receive a Microchip $20 Fee*

YesNo
Pre Surgical AGREEMENT

The Watertown Humane Society uses qualified staff 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 that undergo surgery. Please CAREFULLY read, and ensure you understand, all the information on this agreement before signing your name.
I understand that underlying conditions may exist without anyone knowing about it and may not be observable during the brief pre-surgical exam.*

I agree
I understand and agree to the information stated about regarding surgical risks*

I agree
I understand and agree to use an e-collar on my dog/cat for 10-14 days following surgery*

I agree
I, being lawfully authorized to make decisions on behalf of the animal named/described above (the "Animal"), hereby request and authorize WHS, including its affiliates and each of their employees, volunteers,veterinarians and/or other agents (collectively,"WHS Parties") to recieve, transport, prescribe for, treat and/or administer vaccinations and/or perform an operation on the Animal.*

I agree
I certify that the Animal has not bitten anyone in the last ten (10) days.*

I agree
I understand that the operation I have elected presents some hazards, and that injury to, post-operative infection in, or death of, the Animal may conceivably result, for there is some inherent risk in the procedure and in the use of anesthetics and drugs provided for the procedure, as well as in any vaccines used. I understand general anesthesia will be administered to the Animal for surgery. I understand and accept these risks to the Animal.*

I agree
I understand the inherent risks of failing to maintain current vaccinations and waive all claims arising out of, or connected with, the performance of this operation due to such failure. I understand, in particular, that if the Animal develops kennel cough or other upper respiratory infections after surgery, I am responsible for treatment at my own cost.*

I agree
I understand that WHS and/or any WHS party has the right to refuse any service and/or procedure to any animal for any reason, including, but not limited to, situations where surgery is deemed a health or safety risk. Such refusal is at the sole discretion of the attending veterinarian.*

I agree
I understand that a pre-surgerical exam will be performed on the Animal when possible, but that there are times, in the attending veterinarian's sole discretion, when such an exam may only be performed after the Animal has already been sedated or anesthetized. I understand that the Animal will not receive pre-operative bloodwork at WHS. If I choose for the Animal to have such bloodwork, I understand that it must be performed at a full service veterinary clinic.*

I agree
I understand that some risk factors significantly increase surgical risk, including, but not limited to, pregnancy, heat, and diseases such as heartworms, obesity, blood clotting disorders, endocrine diseases, and senior animals.*

I agree
I understand that if the Animal is an acceptable surgical and/or vaccination candidate, surgical procedures and/or vaccinations will be performed regardless of the Animals gender and/or medical condition, including but not limited to, pregnancy. I understand that if the Animal is pregnant, the pregnancy will be terminated at surgery.*

I agree
If an unforeseen event/emergency situation occurs or a medical condition is discovered that requires urgent immediate medical treatment, I consent that the attending veterinarian may perorm such treatment, or transport the Animal to another veterinarian for the provision of such treatment at my expense, without seeking additional authorization or consent from me.*

I agree
I understand that my further consent will be required for non-emergency treatment EXCEPT in cases where the Animal has an open umbilical hernia, which may be repaired at the time of surgery at an additional charge of $25 without my further consent, and/or agree that if one or more of my male animal's testicles are not descended (cryptorchid) I will be charged $25-$50 per undescended testicle, depending on location. This will be due at the time of pick up.*

I agree
I understand that if I do not show proof of a current rabies vaccination, WHS will automatically administer a one year rabies vaccine to my animal.*

I agree
Surgery drop off is between 8-8:30am and pick up time will between 2-4pm. An additional $15 charge will be applied if picking up tardy.*

I agree
All pets must be leashed or in a carrier when entering and exiting the shelter.*

I agree
Post Surgical AGREEMENT

The Watertown Humane Society is not a full service veterinarian clinic. We are only staffed and equipped to offer spay/neuter services and any follow up care needed for your pet must be done at your regular veterinarian clinic or an emergency veterinarian if needed.
I understand and agree to follow the discharge instructions below to the best of my ability*

I agree
I understand the importance of keeping my pet's incision site dry and clean for the 14 days following surgery*

I agree
I understand that if my pet is attempting to chew, lick, or bite the incision, I will do whatever is necessary to prevent that behavior*

I agree
I understand that there are risks involved in any surgery and I will not hold the Watertown Humane Society responsible for any unforeseen complications*

I agree
I understand that if any complications from the surgery arise I am to contact my local veterinarian for care for my pet*

I agree
I understand that if my regular veterinarian is not able to see my pet, I will take my pet to the soonest available emergency veterinarian clinic*

I agree
I have reviewed the charges associated with the spay/neuter surgery and any additional medical care I wish to have performed and agree to pay in full (minus the deposit paid) at pick up*

I agree
Signature (please use your finger if using a smart phone or mouse if using a computer to electronically sign:*
Should be Empty:

SPECIAL SURGICAL REQUEST FORM

Applicant Information

Pet Information

Special Service Requested

Pre Surgical AGREEMENT

Post Surgical AGREEMENT