Check In and Consent Form Step 1 of 250%OwnerName* First Last PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Treatment Authorization and Release (of pet(s) listed on page 2)1. To my knowledge the animal listed above is in good health. I acknowledge the fact that all pre-and post-operative care is my responsibility. I am the owner and responsible party of the pet(s) listed and have the authority to execute this consent. 2. I understand that if my pet is aggressive and requires extra medication, time, or staff there may be an extra charge. 3. I understand that if my animal is undergoing surgery and is found to have fleas that they will be treated with a flea adulticide at my expense. 4. I hereby also authorize the use of such anesthetics and vaccinations as you deem advisable and the performance of such surgical and therapeutic procedures as you determine necessary. I understand that some risks always exist with anesthesia and/or surgery, vaccination, and treatments and that I am encouraged to discuss any concerns I may have about those risks with the attending veterinarian before the procedures are initiated. My signature on this form indicates that any questions I have regarding these issues have been answered to my satisfaction. 5. I agree to indemnify and hold harmless Spay Neuter Clinic and the attending veterinarian from and against all liability arising out of the performance of all procedures referred to above. 6. I understand that trained personnel will NOT attend hospitalized animals beyond the regular office hours.PAYMENT OF YOUR BILL IS DUE IN FULL AT THE TIME THE ANIMAL IS TREATEDI confirm that all of the information on this form is accurate and true to the best of my knowledge.Signature*Date* Date Format: MM slash DD slash YYYY Pet Information #1Owner's NamePet's NameSpeciesDogCatSexMaleFemaleDOB / AgeColorBreedHas your pet had any serrious illness or injuries in the past?YesNoHas your pet ever had as allergic reaction?YesNoIs your pet on any medications including heartworm or flea preventionYesNoPlease select the services you wish your pet to receive today Spay (includes pain meds and E collar) Neuter (includes pain meds and E collar) Microchip Nail Trim Deworm Rabies Only Felv/Fiv Test HW Test Heartworm Prevention Flea / Tick Prevention Declaw Canine Influenza Dog - Package A: Rabies, DAP, Lepto, Bord Dog - Package B: Rabies, DAP, Lepto, Bord, HW test Cat - Package A: Rabies, FVRCP, Leuk Cat - Package B: Rabies, FVRCP, Leuk, FELV/FIV testPet Information #2Owner's NamePet's NameSpeciesDogCatSexMaleFemaleDOB / AgeColorBreedHas your pet had any serrious illness or injuries in the past?YesNoHas your pet ever had as allergic reaction?YesNoIs your pet on any medications including heartworm or flea preventionYesNoPlease select the services you wish your pet to receive today Spay (includes pain meds and E collar) Neuter (includes pain meds and E collar) Microchip Nail Trim Deworm Rabies Only Felv/Fiv Test HW Test Heartworm Prevention Flea / Tick Prevention Declaw Canine Influenza Dog - Package A: Rabies, DAP, Lepto, Bord Dog - Package B: Rabies, DAP, Lepto, Bord, HW test Cat - Package A: Rabies, FVRCP, Leuk Cat - Package B: Rabies, FVRCP, Leuk, FELV/FIV testPhoneThis field is for validation purposes and should be left unchanged. Like Us On FacebookAppointments & App Our Location