SNVC 501c3 Group Registration Form

Spay Neuter Veterinary Clinic Group Registration Form

Spay/Neuter Veterinary Clinic of the Sandhills 2709 Bragg Blvd, Fayetteville, North Carolina 28303

Thank you for your interest in having the Spay/Neuter Veterinary Clinic of the Sandhills in Fayetteville, NC perform surgeries for your group! Please fill out the information below if you would like to apply to become an active 501 (c)3 with us and be eligible for rescue pricing. As part of the registration form you will find a blanket high risk waiver for you to sign.

Once we receive this registration form back we will email you the price sheet and appointment information packet.

Thank you for all you do to help animals and for working with the Spay Neuter Vet Clinic!

Name of Group:*

Address for Group:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

501 (C)3 Number for Group:*

Provide Documentation Verifying 501c3 Status

Main Contact for Group:*

Phone Number for Main Contact:*

Please enter a valid phone number.

Address for Main Contact if Different from Group Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email for Main Contact Person:*

example@example.com

Contact for Billing if different:

Phone Number for Billing:

Please enter a valid phone number.

Preferred Billing Method:*

Have a credit on your account and be notified when credit reaches a certain pointHave a credit card on file & pay with credit card the day of surgeryOther

Please note if paying by credit card, any balance due will be charged to the card on file on the day of surgery or when the weekly reconciliation is performed. You will not be notified prior to the card being run.

Person authorized to schedule an appointment:*

Additional person, if any, authorized to schedule an appointment:

If an individual claims to be under your group at drop off, what verification material will they have? (Ex: Voucher, only appts you make)*

Do you authorize an individual to be put under your group without prior authorization or should we turn them away and have them contact your group?*

Preferred Method for Appointment Deposits or missed appointment fees:*

Have a credit on your account and be notified when credit reaches a certain pointHave a credit card on file & pay with credit card the day of surgeryOther

Person authorized to sign a high risk waiver and overnight emergency care if needed:*

Additional person, if any, authorized to sign a high risk waiver and overnight emergency care if needed:

If we have a blanket High Risk Waiver and are not able to reach you about a certain animal, would you like us to proceed based on Dr’s recommendation, understanding that the group would potentially need to cover emergency after care?*

YesNo

Are the animals that you bring to us privately owned, or owned by the Non-profit group? If animals are privately owned your group would be considered a voucher group and each owner needs to fill out a high risk waiver form as well as an admission form. This allows us to proceed with surgery if we are unable to reach the owners during the surgical day.*

Privately Owned (Voucher Group)Group is the owner (Rescue Group)Both owned by rescue and privately owned (we will set up two accounts)

All groups are responsible for all fees associated with surgery, other required services and any finance or late fees. This includes anything required for surgery or associated with surgery, for example cost assiciated with all weight ranges of surgery, if the pet is cryptorchid, rabies vaccination if CRV not provided, antibiotics if required, and any late or cancelation fees.

Cats are required to be brought in individual secure carriers. If cats are not in individual secure carriers, the group will be billed for cardboard carrier.

For Rescue Groups, all services requested at the time of booking and on the day of the appointment will be billed directly to the Rescue Group.

For those who bring privately owned animals and will be setting up a voucher group account: Does your group cover any of the following additional expenses or will they need to be paid by person dropping off or owner of the pet? (If not paid by group, any applicable fees will need to be paid by person dropping animal off before they can leave the pet. Please understand that if, for example, you check you don't pay for late fees and the person dropping off is late, they have to pay that fee at drop off or they will be turned away and group will be charged the no-show fee.) Any other fees, including surgery cost and late pick up fee, not listed are automatically billed to the group*

	Yes	No
Additional Vaccines Beyond Rabies
Hernia Repair
Heartworm Test and Prevention
Flea/ Tick Prevention
Late Drop Off Fee
Additional recommended diagnostics such as bloodwork, ear cytologies or fecals.

General Surgical Admission Form - Please read and sign below:

I, acting as owner or agent of the pet named above, hereby request and authorize SNVC to perform an operation for sexual sterilization of the animal named above.

I understand that any anesthetic/surgical procedure, including surgical sexual sterilization, presents a degree of risk to the patient and, though minimal, may result in injury or death.
I certify that my animal is in good health and not on any medications other than those disclosed.
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 or due to such failure.
I understand that some factors significantly increase surgical risk, including but not limited to; pregnancy, being in heat, recently post-partum, obese, brachycephalic or over 7 years in age, having a heart murmur and diseases such as Feline Immunodeficiency Virus (FIV), Feline Leukemia, and heartworm disease.
I understand that blood work and/or veterinary diagnostic prior to surgery is recommended for all high risk pets.
I understand that if my pet has a pre-existing medical condition, clinical or subclinical, this condition may be worsened by anesthesia and/or surgical sterilization.
I understand that if my animal is pregnant, the pregnancy will be terminated at surgery.
I understand that SNVC has the right to refuse service to any animal determined to be ill or at increased risk. Sick animals are at higher risk for anesthetic and surgical complications, as well as pose a risk to other animals in the clinic.
I understand that SNVC may not perform a complete physical examination before surgery is performed. I also understand that my animal will not receive pre-operative blood work unless requested and waive my right to have this service performed prior to surgery.
I understand that if there are complications my pet may need to receive post-operative monitoring or care at an emergency clinic and I accept the financial responsibility for that care if deemed necessary by the veterinarian.
I understand that my animal should have no food after 12:00 midnight the evening prior to surgery (excluding pets less than 4 months old).
I understand that if my animal has an open umbilical hernia, it may be repaired at time of surgery for an additional fee.
I understand that if my male animal is a cryptorchid there will be an additional fee for surgery.
I understand that photographs may be taken during the day, and my pet may be present in those photos. I understand that the photographs taken at SNVC may be used for promotions and advertisements for SNVC. This includes but is not limited to Facebook, Twitter, SNVC website, advertisements, etc.
I understand that if I do not retrieve my pet at the agreed upon time, SNVC may exercise their right to turn the animal over to the nearest animal control center, humane society, or dispose of as deemed just and proper as allowed by the State of North Carolina under G.S. 90-187.7(a). Owners of pets left after closing at 5pm will be charged a 25.00 per half hour late fee. Owners dropping Pets off past the intake time of 8:00am will be charged a 25.00 late drop off fee and may be turned away for surgery and asked to reschedule.
I understand that payment in full is required prior to services being rendered.
I agree to allow SNVC to run any Credit Card(s) on file to cover any remaining balance due. Payments may be processed after the day of surgery.
I understand that under no circumstances will the Spay Neuter Veterinary Clinic pay for services received at another veterinary clinic, whether the services are related to a surgery done at the Spay Neuter Veterinary Clinic or not.
I understand that there will be a small permanent green line tattoo next to the incision indicating sterilization.
I understand that my animal may receive a nail trim and occasionally nails are quicked in the process.

I understand that my animal's fur will be shaved to ensure sterility during the surgical procedure.
I understand that if the Clinic has any questions regarding your pet or there is reason for concern or increased risk with surgery noticed prior or during surgery, the clinic will attempt to reach the owner at the numbers left at check in. IF THE OWNER IS NOT REACHABLE BY 10AM DAY OF SURGERY I UNDERSTAND THAT SURGERY MAY NOT BE DONE ON MY ANIMAL and you may need to reschedule your appointment
I hereby release the Spay Neuter Veterinary Clinic of the Sandhills, all veterinarians, assistants, volunteers, directors, and employees from any and all claims arising out of or connected with the performance of this procedure or any adverse reactions from vaccinations. I agree that I have not and will not claim any right of compensation from any of the above, or file action by reason of such sterilization or attempted sterilization of such animal or any consequences related thereto. Owner/agent hereby agrees to hold SNVC unaccountable for any damages caused during the transportation of the animal, or for any damages caused by any unforeseeable events including fire, vandalism, burglary, extreme weather, natural disasters or acts of God.

Waiver for High Risk Surgery for Animals Transported by a Group / Blanket Waiver

Your animal could be at increased risk due to any of the following:

· Medical condition or illness (respiratory infection, GI disease, parasites, skin disease such as Demodectic mange)

· Physical exam finding (heart murmur, fever, poor condition, overweight)

· Age (over 7 years old in general)

· Late term pregnancy

· Recent pregnancy or Mammary Dev (Must wait AT LEAST 3-4 months from delivery)

· Previous C-Sections

· Brachycephalic animals (Bulldog, Pug, Boston) or other Breed Concerns

· Feral or aggressive – unable to examine

Risks from surgery include, but are not limited to, surgical, anesthetic or post-surgical complications, including death. Some medical conditions (such as heart conditions and skin conditions) can be worsened with anesthesia and results may not be apparent immediately.

Your animal may receive skin staples or antibiotics at an additional charge.

If there are additional concerns, it is the recommendation of the SNVC that your animal receives a diagnostic work-up and medical evaluation/care PRIOR to undergoing surgery. Diagnostic work-up may include: physical exam, ultrasound, ECG, radiographs and/or blood work.

Understanding fully all of the above, I choose to have my animal’s procedure performed at the Spay/Neuter Veterinary Clinic of the Sandhills and accept all risks associated with this decision. I will not hold the Spay Neuter Veterinary Clinic of the Sandhills or any of its employees or associates liable for any consequences associated with this procedure.

Final decision as to whether surgery is performed is up to the doctor on the case. If the doctor feels the animal is at severe risk, SNVC has the right to refuse or stop surgery at any time. Owners will be charged for the procedure once the animal is anesthetized.

If there are surgical or post-surgical complications and the doctor feels it is necessary for the animal to remain overnight for observation or additional care the animal will be transferred to an Animal Emergency Clinic at the expense of the owner. It is up to the discretion of the doctor whether the animal needs overnight care, and by signing this waiver you agree to pay for and receive the recommended care. A credit card or deposit will be required at the Emergency Clinic.

Name of Authorized Signer for Group:*

First NameLast Name

Initials of Authorized Signer for Group:*

Signature*

Date