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Dogwood Park Spay/Neuter Clinic Surgery Date:_____________________706-541-2911

Your First Name: _____________________ Your Last Name: ________________________ Landline/Home #:___________________

Cell #:________________Work #:__________________ Email: _____________________ Emergency Contact: __________________

Address: _________________________ City: ____________________ State: __________ Zip Code: __________________________

Pets Name: ______________________ Species: Cat Dog Breed: __________________________ Sex: Male Female

Age: _________ Colors/Markings: ________________________________ Current Medications/Supplements: ___________________

Dogwood Park Spay Neuter Clinic uses qualified staffing and approved materials for all procedures performed. It isimportant for you to understand that the risk of injury or death, although extremely low, is always present just as it isfor humans who undergo surgery. Carefully read and understand the following before signing your name.

I, acting as owner or agent of the pet named above, hereby request and authorize Dogwood Park Spay Neuter Clinic, throughwhomever veterinarians they may designate, to perform an operation for sexual sterilization of the animal named on the above portionof this form. Please initial below that you have read and understand the following. If you do not understand or have questionsplease do not hesitate to ask a staff member.

_________I understand that the operation presents some hazards and that injury to or death of such an animal mayconceivably result, for there is some risk in the procedure and the use of anesthetics and drugs in providing this service.

_________I certify that my animal has been vaccinated against Rabies within one year prior to this date. I understand that if cannot show proof of vaccination my pet will be vaccinated against Rabies at no additional charge.

_________I understand that there are inherent risks of exposing my pet to other animals if they are not current on theirvaccines. I understand that it takes up to two weeks for vaccinations to protect my animal.

_________I understand the inherent risks of failing to maintain current vaccinations and waive all claims arising out of orconnected with the performance of this operation due to such failure.

_________I understand the inherent risks of failing to maintain current Heartworm Preventative and waive all claims arisingout of or connected with the performance of this operation due to such failure.

_________I certify that my animal is in good health and has had no food since Midnight the night prior to surgery.

_________I understand that Dogwood Park Spay Neuter Clinic has the right to refuse service to any animal to whom surgeryis deemed a health risk.

_________I understand that it is my responsibility to alert Dogwood Park Staff of any health conditions or concerns I haveregarding my pet.

_________If your pet is 7 years old or older our veterinarians recommend blood work and IV catheter and fluids. I authorizeDogwood Park to perform these added procedures and understand there will be additional costs incurred as a result.Additional Fee $35-$55

_________I understand that some factors significantly increase surgical risk, including but not limited to diseases such asFeline Immunodeficiency Virus, Feline Leukemia, and heartworms.

_________I understand that being in heat increases the risk of surgery and also that there will be an extra charge for

performing surgery on animals that are in heat. Additional Fee $20-$40.

_________I understand that if my animal is pregnant, the pregnancy will be terminated during surgery. I understand thatpregnancy increases the risk of surgery and also that there will be an extra charge for performing surgery on animals that arepregnant. Additional Fee $20-$40.

_________I understand that if my animal has an umbilical hernia, inguinal hernia, is cryptorchid or needs retained deciduousteeth removed it will be repaired at time of surgery at an additional charge. Additional Fee $10-$40.

_________I understand that if my animal is found to have fleas, ticks, tapeworms or other parasites, which have the potentialto infect other surgery patients, my pet will be treated and an additional cost for that treatment will result.

_________I understand that if my animal tests positive for Heartworms or FeLV/FIV Dogwood Park may perform surgeryunder the doctors discretion.

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_________I understand that if I dont retrieve my pet at the agreed upon time that Dogwood Park Spay Neuter Clinic will exercise itsright to either turn the animal over to the nearest humane society or dispose of as deemed just and proper as allowed by the State ofGeorgia. Owners of pets left after the agreed date or time shall be charged a boarding fee of no less than $25 per night.

_________I hereby release the Dogwood Park Spay Neuter Clinic, Columbia County Humane Society, all veterinarians, assistants,volunteers, directors, and employees from any and all claims arising out of or connected with the performance of this procedure or anyadverse reactions from vaccinations. I agree that I have not and will not claim any right of compensation from them, or any of them, orfile action by reason of such sterilization or attempted sterilization of such animal or any consequences related thereto. Owner/ agenthereby agrees to indemnify and hold Dogwood Park/CCHS harmless 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.

________ I have a voucher to cover the cost associated with my pets surgery from an approved rescue organization.

Approved Rescue Group Authorizing Services: _______________________________________________

________I HAVE PROOF OF CURRENT RABIES VACCINATION

Do you have any concerns about your pets current health status? If yes please describe here: Yes No

__________________________________________________________________________________________________________

YOUR ANIMAL WILL RECEIVE A FREE RABIES VACCINE IF PROOF OF RABIES IS NOT PROVIDED

Requested Vaccines and ServicesSpay (Female) Neuter (Male) Dewclaw RemovalFeline Leukemia Vaccine Canine Distemper/Parvo Vaccine Hernia RepairFeline Distemper Vaccine Canine Kennel Cough Vaccine Nail TrimRabies Vaccine Feline FeLV/FIV Test Heartworm TestDental Microchip Feral Cat Ear Tip (L)Pro-Heart Injection Other_________________________________________________

SIGNATURE DATESTAFF USE ONLY

Surgical Checklist To Be Completed Before Any Medications are Given Anesthesia/Pain/ABX

Surgery Performed Spay Neuter Dental Other

Pre-Op Exam Performed Dr. HR Dr. KD Dr. LJ Dr.NR Dr.

Vaccines Performed Rabies DHPP KC FVRCP FELV

Injections Proheart

Weight & BCS 1 2 3 4 5

Additional Treatments/ChargesComplications Pregnant In Heat

Cryptorchid (Abd) Cryptorchid (Ing) Left Right

Umbilical Hernia Inguinal HerniaDental Extractions # Grade: I II III

Additional Treatments Microchip Capstar Praziquantel Inj: ml

Geriatric Treatments IV Cath IV Fluids Adult Profile

Heartworm Test Results Negative Positive Inconclusive

Fecal Results Negative Positive:

FELV Test Results Negative FELV Positive FIV Positive

Post Op Instructions:__________________________________________________________________________________________

___________________________________________________________________________________________________________

Feline 1:1:1Ket/Dol/Dom _____ml

Canine 1:1 SmallDomitor/Dolorex _____ml

Canine 2:1 LargeDolorex/Xylazine _____ml

Canine 1:1Ketamine/Valium _____ml

Rimadyl _____ml

Penicillin _____ml