Spay/Neuter Form

Fix-a-Dog Spay/Neuter Voucher $50 Rabies/Distemper vaccine add'l $20

Newberry County Resident Pet Owners Only - no rescues, shelters, or fosters
After purchasing voucher, owner must:
- Contact a partner veterinary office (below) to Shedule an appointment
- Transport pet to and from partner veterinary facility
- Must adhear to partner veterinarian's scheduling & cancelation policies
Select Partner Vet*

Pet Care of Newberry 803-276-2498Triangle Veterinary Care (Union) 864-427-3177
Date and Time*

MonthDayYearHourMinutesAM/PM Option
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
E-mail*
Complete Pet information
Patient 1 Name*
Patient 1 Birthdate*

MonthDayYear
Patient 1 Sex*
Patient 1 Breed*
Patient 1 Description*
Color
Patient 1 Weight*
lbs

Patient 2
Patient 2 Name
Patient 2 Birthdate

MonthDayYear
Patient 2 Sex
Patient 2 Breed
Patient 2 Description
Color
Patient 2 Weight
lbs

Patient 3
Patient 3 Name
Patient 3 Birthdate

MonthDayYear
Patient 3 Sex
Patient 3 Breed
Patient 3 Description
Color
Patient 3 Weight
lbs

Patient 4
Patient 4 Name
Patient 4 Birthdate

MonthDayYear
Patient 4 Sex
Patient 4 Breed
Patient 4 Description
Color
Patient 4 Weight
lbs

Vaccines Must Be Current or Purchased with Voucher
** Terms of Service **

I hereby authorize the surgical sterilization of the aforementioned animal by one of the Newberry County Humane Society partner veterinarians. I acknowledge the fact that I need to abide by all pre- and post-operative care required by the veterinarian.

To my knowledge the above animal is in good health unless noted. I certify that I will present records verifying that my animal has had necessary vaccines within one year prior to this date or I will agree to recommended vaccines at the time of surgery. I understand that the veterinarian has the right to refuse service to any animal to whom surgery is deemed a health risk. I also understand that the veterinarian will not be performing a complete health examination on the animal prior to surgery.

I am at least 18 years of age and the owner of the above animal or am responsible for it and have the authority to execute this consent. I hereby also authorize the use of such anesthetics as you deem advisable and the performance of such surgical or therapeutic procedures as you determine necessary. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) are initiated. I agree to indemnify and hold harmless Newberry County Humane Society and the attending veterinarians from and against any and all liability arising out of the performance of all procedures referred to above.

I understand that it is my responsibility to notify the veterinary office according to their scheduling policy if I need to reschedule. I understand that I need to drop off and pick up my animal at the times required by the veterinary office. I also understand that Newberry County Humane Society's voucher will pay for the spay/neuter & vaccines (if purchased, and depending on vet). I understand that vouchers are valid for 6 months, are for one-time use only, are non-transferrable, & nonrefundable. I understand that this is a good time to get a microchip, FIV/FeLV combo test, de-worming, pain medicines, etc. and that payment for those are my responsibility.
Signature*

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Service

Fix-A-Dog$50.00

Fix-A-Dog	Quantity	Price
Fix-A-Dog w/o Rabies Distemper		$50.00
with Rabies/Distemper		$20.00

Total $0.00

Credit Card

Fix-a-Dog Spay/Neuter Voucher $50 Rabies/Distemper vaccine add'l $20

Complete Pet information

Vaccines Must Be Current or Purchased with Voucher

Credit Card