Owner/Caretaker Name
*
First Name
Last Name
Owner/Caretaker Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Owner/Caretaker Phone
*
(###)
###
####
Alternate Phone
(###)
###
####
Animal Name
*
Animal Species
*
Animal Breed
*
Animal Color
*
Animal Sex
*
Male
Female
Feline Only - Please Select
Indoor
Outdoor
Both
Animal weight
Primary Care Veterinarian
*
Primary Care Veterinarian
*
(###)
###
####
History of seizures
*
Heart conditions
*
Bleeding disorders
*
Liver or kidney disease
*
Ear infections
*
Skin infection
*
Fleas
*
Coughing or sneezing
*
Vomiting or diarrhea
*
Problems with anesthesia in the past
*
Allergies to medications
*
Any additional medical concerns
*
If yes, please explain in next field.
If yes, please explain
List all current and recent medications
*
Date of last rabies and distemper vaccine
If unknown, leave blank.
MM
DD
YYYY
Date of last FeLV/FIV test - Feline only
If unknown leave blank.
MM
DD
YYYY
Date of last Heartworm test - Canine only
If unknown leave blank
MM
DD
YYYY
Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
Please select one of the following options
*
If your pet is female, has she gone into heat yet?
If yes, date of end of last heat
If currently in heat, there will be an additional charge of at least $30 but may exceed $100 if there are intraoperative complications with bleeding.
MM
DD
YYYY
Is there any possibility of pregnancy?
(If pregnant, there will be an additional charge depending on species and time of gestation.)
If your pet is male, are both testicles descended?
Feline Clinic Services
*
Please Note: All outdoor cats will be ear tipped as an indicator of sterilization**
Canine Clinic Services
*
CPR STATUS AUTHORIZATION*
*
Name
First Name
Last Name
Date
*
MM
DD
YYYY
POST SURGERY & RECOVERY*
The post-operative period is important for the healing process of your pet’s surgical procedure. You will be provided with recovery instructions at the time of discharge; however, please keep your pet calm and quiet for 10-14 days post operatively. No bathing, no running or jumping. Leash walks only for dogs. A cone collar is strongly recommended for all patients post operatively. The cost of this cone collar is an additional $15.00.
While you may make every effort to keep pets calm and quiet at home, there are some pets that are more excited and active than others. If this is the case, we can provide a mild sedative to go home for your pet. The cost of this medication is an additional $15.00. Please note that cats do not always require this additional medication, but it can still be beneficial.
Animal Name
*
Animal Caretaker Name
*
First Name
Last Name
SURGICAL CONSENT*
I am the owner or authorized agent of the pet named above and I am at least 18 years of age and have the authority to execute this contract. I hereby give Columbia Animal Shelter, its veterinarians, authorized agents, staff, and representatives consent and authority to perform surgery on the animal named above.
I certify that my animal is in good health and that if it is over four months old that it has not eaten since 12AM (midnight) last night.
I understand that it is recommended my pet be current on flea/tick medication. I also understand that if live fleas are seen on my pet, they will be given a Capstar pill, at a cost of $10, to kill the live fleas as to not contaminate the hospital or other pets.
I understand that a Rabies vaccine is required by PA state law once a pet reaches 12 weeks of age. If I cannot provide proof of a current Rabies vaccination, Columbia Animal Shelter has permission to give a Rabies vaccine to my pet at the cost of $30.00.
I understand it is recommended that my pet also be current on all other vaccinations. Columbia Animal Shelter is not responsible for possible consequences if my pet is not current on their other vaccinations.
I understand the benefits of spay/neuter and routine vaccination and understand that there are potential complications related to such procedures including vaccine reaction, persistent bleeding, infection, anesthetic side effects, surgical dehiscence, etc., and that Columbia Animal Shelter is not responsible for these complications.
I understand that Columbia Animal Shelter will perform a physical examination before surgery is performed. I understand that while I have the right to waive pre-operative bloodwork, doing so may prevent the detection of underlying illnesses and/or diseases which may compromise my pet's health during and/or after anesthesia.
I understand that some health conditions significantly increase surgical risk, including but not limited to, pregnancy, heat, and diseases related to the heart, liver, and kidneys.
I understand that if my animal is pregnant, in heat, has an undescended testicle (Cryptorchid), or any other abnormality, there will be an additional minimum charge to me of $50-$100. This is due to additional surgery and anesthesia time required to perform the procedure. I understand that if my animal is pregnant, the pregnancy will be terminated during surgery, and there will be a minimum charge to me of $40-$100.
I understand that if my animal has an open umbilical hernia, it will be repaired at time of surgery at an additional minimum charge to me of $100.
I have been informed that there are certain risks and complications associated with any operation or procedure, however rare, including injury and death. I further understand that during the anesthesia period and course of the operation, unforeseen conditions may arise that may necessitate the performance of additional procedures.
I authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedure, and I understand that there are risks associated with the use of any anesthesia and medication. I further understand that support personnel, including clinic staff, volunteers, and veterinary students, will be used as deemed appropriate by the veterinarian. I understand that qualified veterinary students, supervised by the veterinarian, may perform all or part of surgical procedures.
I understand that my animal will receive an approximately 1cm green tattoo on its abdomen as part of the spay/neuter surgery today. This may appear darker immediately after surgery but will fade to a faint line. This tattoo will provide an easy way to identify my animal as “sterilized.” I understand that all Trap Neuter Return (TNR) patients will receive an ear tip, in addition to the green tattoo.
I understand that Columbia Animal shelter strongly recommends the purchase of an e-collar and as part of every surgery. The e-collar must remain on as instructed to help prevent post-operative infection or complications, and that if I say I have one at home and do not purchase one at time of pick-up, and/or fail to ensure that my pet wears it properly, I will be financially responsible for any infections or complications that may arise as a result. This may result in over $1000 in veterinary fees at other hospitals/emergency hospitals. We do not provide emergency care.
I understand that if I do not retrieve my pet(s) at the agreed upon time I will be charged a boarding fee of no less than $25 per night. I further understand that if I do not claim my pet within two days of discharge time, Columbia Animal Shelter can assume that I have abandoned all ownership rights to the animal and has been authorized to place the animal up for adoption. I will remain responsible for any treatment and boarding costs. I understand that if I pick up my pet past the agreed upon pickup time, I will be subject to a $25 late fee.
I understand that Columbia Animal Shelter has the right to refuse service to any animal for whom surgery is deemed by a veterinarian to be at risk for surgical complications and/or other health risks, as well as too aggressive to handle by the staff.
I hereby release Columbia Animal Shelter, its veterinarians, assistants, volunteers, director, and employees from any and all claims arising out of or connected with the performance of this procedure or any adverse reactions my pet may have to vaccinations, medications, anesthesia, and/or the surgical procedure.
I will not hold Columbia Animal Shelter, its veterinarians, or any team member liable for any complications that may arise. I further agree to indemnify and hold Columbia Animal Shelter harmless for any damages caused during the transportation or treatment of the animal, and for any damages caused by any unforeseeable events including fire, vandalism, burglary, extreme weather, natural disasters or acts of God.
I have confirmed my pet's cardiopulmonary resuscitation (CPR) directive with a veterinary team member.
I agree to pay in full for services rendered today at the conclusion of my visit, and I understand that Columbia Animal Shelter does not offer any payment plans, credit, or client account. Columbia Animal Shelter accepts cash, checks and all major credit cards.
I HAVE CAREFULLY READ AND FULLY UNDERSTAND THIS SURGERY / ANESTHESIA CONSENT FORM AND I AGREE TO PAY ANY INCURRED CHARGES IN FULL PRIOR TO MY PET BEING DISCHARGED.
Animal Name
Animal Caretaker Name
First Name
Last Name
Date
MM
DD
YYYY
