Spay/Neuter Clinic Registration

Spay/Neuter Clinic Registration
Spay/Neuter Clinic Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How many pets are you registering today?
This form allows up to 10 registrations; if you have more than 10, please submit an additional form(s) for the remainder
Owner/Primary Contact Name

First NameLast Name
Organization Name (if applicable)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
You'll be called at this number when it's your turnFormat: (000) 000-0000.
Email
example@example.com; all receipts will be emailed

- I certify that I am the legal owner or authorized agent of the animal(s) listed in this registration and hereby consent to examination, anesthesia, spay/neuter surgery, vaccination, microchipping, and/or other services as selected for my animal(s). I acknowledge that payment is due at the time services are rendered and that fees are non-refundable once services have begun.
- I understand that spay/neuter surgery and related veterinary procedures carry inherent risks, including but not limited to infection, bleeding, adverse drug or anesthetic reactions, unforeseen complications, or, in rare cases, death. I acknowledge that no guarantees have been made regarding the outcome of any procedure or service.
- I certify that, to be best of my knowledge, my animal(s) are healthy enough to undergo the requested procedures, have not eaten as instructed (if applicable), and have not had any recent illnesses, injuries, or conditions that would make surgery unsafe unless disclosed on this form.
- I voluntarily assume all risks associated with participation including potential side effects or rare adverse reactions - up to and including death - and agree to release and hold harmless Southwest Cat Initiative, it's veterinarians, staff, volunteers, hosting organization, and affiliates from any and all claims, damages, or liability arising from to services provided, except in cases of gross negligence or willful misconduct.
- I understand that this is a high-volume, low-cost clinic and that services are limited to those offered at this event. I agree that if an unexpected medical emergency occurs, the clinic staff may provide reasonable care as deemed necessary. I understand that advanced or emergency care outside the scope of this clinic may require referral to a full-service veterinary hospital at my own expense and will not be reimbursed by the organization.
- I consent to the use of photographs of my self and my animal(s) taken during the clinic for promotional purposes by Southwest Cat Initiative, it's host organization, and/or it's affiliated groups.
- ELECTRONIC SIGNATURE (REQUIRED)
- By signing below, I acknowledge this form serves as my electronic signature and that I have read, understood, and agreed to all statements above and that I have no additional questions regarding my pet's health.
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
  MinutesAM/PM Option
Should be Empty:

Spay/Neuter Clinic Registration

ELECTRONIC SIGNATURE (REQUIRED)