FELINE SPAY/NEUTER CLINIC INTAKE FORM

Once you have submitted this form a shelter staff member will contact you to schedule an appointment slot.

PERSONAL INFORMATION
Owner/Caretaker Name *
Owner/Caretaker Name
Owner/Caretaker Address *
Owner/Caretaker Address
Owner/Caretaker Phone *
Owner/Caretaker Phone
Alternate Phone
Alternate Phone
PET INFORMATION
**PLEASE NOTE - WE ARE ONLY ACCEPTING CATS FOR SPAY/NEUTER CLINICS AT THIS TIME**
OR APPROXIMATE BIRTHDAY/AGE IF EXACT BIRTHDAY IS UNKNOWN.
Primary Care Veterinarian *
Primary Care Veterinarian
PET MEDICAL HISTORY
Does your pet have any of the following?
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.
Date of last rabies and distemper vaccine
Date of last rabies and distemper vaccine
If unknown, leave blank.
Date of last FeLV/FIV test
Date of last FeLV/FIV test
If unknown leave blank.
If your pet is female, has she gone into heat yet?
If yes, date of end of last heat
If yes, date of end of last heat
(If currently in heat there will be an additional charge of $20.00)
Is there any possibility of pregnancy?
(If pregnant, there will be an additional charge of $35.00)
If your pet is male, are both testicles descended?
PLEASE SELECT WHICH SERVICES YOU WANT US TO PERFORM ON YOUR PET AT THE APPOINTMENT
Please note: All surgical patients will receive a small, green tattoo near the incision site. The tattoo will ensure that anyone examining your animal knows they have been sterilized.
Feline Clinic Services *
PRE-ANESTHETIC BLOOD TESTING
Before undergoing anesthesia, a physical exam will be performed. As part of the pre-surgical examination, we recommend pre-anesthetic blood. Many conditions cannot be detected without blood work and there is always a possibility that a physical exam alone will not identify all of your pet’s health issues. Having pre anesthetic blood work performed can greatly reduce the risks of complications as well as identify medical conditions that could require medical treatment in the future.
Please select one of the following options *
PLEASE NOTE
When scheduling a spay/neuter a non-refundable deposit of $50.00 is required to hold your appointment, and will be counted towards your total bill once surgery is complete. Pennsylvania state law requires a current rabies vaccination for your pet. Please bring proof in the form of a certificate (tags are not acceptable forms of proof). If unable to provide proof of up-to-date Rabies, one will be automatically administered at a cost of $15.00
PRIOR TO SURGERY
Pets must be kept indoors or confined the night before surgery. This ensures that they are not eating outside, which could potentially be dangerous during surgery. Adult animals must have food taken away the night before surgery at midnight with no additional feedings prior to surgery. Animals four months or younger may have food. All pets are allowed to have water prior to surgery. Patient check-in is Tuesdays: Between 8:00am and 8:30am Patient pick up is between 4:00pm and 4:30pm Dogs and cats that are at a higher risk of disease exposure (boarding facilities, day care, dog parks, socialization with other animals) should receive both core and non-core vaccines. These are as follows:   Core vaccines for cats include rabies and feline panleukopenia(distemper)/rhinitis. Core vaccines for dogs include rabies, canine distemper, parvovirus, and hepatitis. Non-core vaccines are those that are only recommended for dogs and cats that are at higher risk, or live in certain geographical areas. Non-core vaccines for cats include the feline leukemia vaccine. Non-core vaccines for dogs include canine parainfluenza, canine influenza (H3N8 and H3N2), Bordetella (kennel cough), leptospirosis, and Lyme (Borrelia burgdorferi). Pennsylvania state law requires a current rabies vaccination for your pet. Please bring proof in the form of a certificate (tags are not acceptable forms of proof). If unable to provide proof of up-to-date Rabies, one will be automatically administered at a cost of $15.00   Columbia Animal Shelter maintains the highest levels of cleanliness and disinfects all surfaces between patients; however, we cannot guarantee that your pet will not be exposed to contagious disease. Therefore we strongly recommend that all pets visiting our shelter and clinic be current on their core and non-core vaccinations. It is important to understand that no vaccine is 100% effective.   We also recommend pets be protected from fleas with topical or oral preventative. 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 Clinic or other animals.
E-SIGNATURE *
E-SIGNATURE
I have read the above information pertaining to vaccination recommendations. I am aware that if my pet is not current on vaccines, and has not been protected from fleas and ticks, Columbia Animal Shelter cannot be held liable for associated diseases, treatment, or complications that may occur. Please type your first and last name to indicate you understand.
Date of Signature *
Date of Signature
SURGICAL CONSENT
By typing my name in the box below box I certify that I am the owner or agent for the owner, of the above named pet and have the authority to execute this consent. I authorize anesthesia, surgery and treatment for my pet. I understand unforeseen conditions may necessitate an additional or different procedure(s) in the professional judgment of the veterinarian. I also authorize the use of appropriate anesthetics and medications deemed necessary by the veterinarian. I understand surgery and anesthesia may have risks and complications including bleeding, infection and others that can result in injury to the animal up to and including death in rare cases. I fully understand these risks and understand that veterinarians and clinic staff will try to minimize such risks. I will not hold Columbia Animal Shelter responsible for these risks or complications and hereby hold Columbia Animal Shelter harmless regarding any and all liability that may be associated with these procedures. I agree to pay in full for all services rendered, including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. 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 $15.00. 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 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 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.
Animal Caretaker Name *
Animal Caretaker Name
Date *
Date