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Client Information and Surgical Consent Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
If you would like to add another person to your pet's account, please provide their name and phone number:
Pet's name
*
Pet's sex
*
Male
Female
Pet's species:
*
Dog
Cat
Pet's age
*
Please specify weeks, months, years
Pet's breed
*
Pet's color
*
Has your pet ever had an allergic reaction to a vaccine or medications?
*
Please Select
Yes
No
Is your pet currently taking any medications?
*
Please Select
Yes
No
Has your pet ever had a seizure or been diagnosed with a heart issue?
*
Please Select
Yes
No
Has your pet experienced any of the following in the last two weeks?
*
None
Coughing/sneezing
Weight loss
Diarrhea
Vomiting
Loss of appetite
Other
Please list any previously diagnosed medical issues, medications your pet is currently taking, or if you answered "other" to the question above, please describe:
Blood work is an important step for any pet undergoing anesthesia. Animals are very capable of hiding illness and can suffer from disease without showing any outward signs. A blood panel can help minimize risk of anesthetic, surgical, and postoperative complications by checking for pre-existing liver disease, kidney disease, anemia, infection and other conditions. This testing is STRONGLY recommended for pets over the age of 7 years. $60
*
Please Select
Yes
No, I understand the risks and waive my option to have bloodwork done on my pet.
I understand that my pet must have paper proof of a current rabies vaccine. If paper proof is not provided, a rabies vaccine will be administered for an additional fee of $15.
*
Please initial above.
I understand that I will be charged a fee of $20 per night if my pet isn't picked up at the designated time. I also understand that any pet left for 72 hours or more will be considered abandoned and Paws Humane will exercise its right to either turn the animal over to Columbus Animal Control or dispose of the animal as deemed just and proper. At the cessation of the work week, all remaining animals that have not been picked up will be turned over to Animal Control for staff safety and liability issues.
*
Please initial above.
I understand that my pet will receive a small tattoo on their abdomen to show that they have been sterilized.
*
Please initial above.
I understand that in case of a post-op emergency or complication, or if my pet damages or removes the surgical sutures, it will be my responsibility to take my pet back to the Paws Humane Spay/Neuter Clinic during normal business hours or to my private veterinarian if after hours. I will assume responsibility of all charges incurred.
*
Please initial above.
I understand that some factors significantly increase surgical risk, including, but not limited to, age, pregnancy, heat, obesity, and diseases such as feline immunodeficiencyvirus (FIV), feline leukemia (FeLV), and heartworms.
*
Please initial above.
I understand that additional charges will apply for animals with hernias, undescended testicles, overweight, in heat or pregnant animals and pyometras.
*
Please initial above.
I understand that any animal found to be pregnant during her sterilization procedure will have her pregnancy terminated.
*
Please initial above.
I understand that Paws has the right to refuse service to any animal to whom surgery is deemed a health risk.
*
Please initial above.
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.
*
Please initial above.
I hereby authorize the surgical sterilization of the aforementioned animal. To my knowledge the above animal is in good health. I acknowledge the fact that all pre- and post-operative care is my responsibility. 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 concernsI have about those risks with the attending veterinarian before the procedure(s) are initiated. My signature on this form indicates that I understand additional charges may apply and any questions I have regarding these issues have been answered to my satisfaction. I agree to indemnify and hold harmless the Paws Humane Spay/Neuter Clinic and the attending veterinarians from and against any and all liability arising out of the performance of all procedures referred to above. My signature below indicates that I am aware that photographs or video taken today may be used in printed or online materials to promote Paws Humane Society and that I may receive promotional emails from the organization that I may unsubscribe to at any time.
Signature
*
I agree and certify I am signing this document voluntarily, and it is my signature, with full knowledge and consent to conduct this transaction electronically.
*
I Agree
Submit
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