Date of Surgery* Is this a pet or feral animal (please check answer) Pet Feral First Name* Last Name* Pet's Name* Pet’s age or DOB* Cat Dog Male Female Has your pet had a litter? Yes No Date last litter was born? When was your pet’s last heat? Pet’s color(s) Pet’s breed Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home phone with area code Cell phone with area code BEST NUMBER TO REACH YOU TODAY HELPING PAW Veterinary Services uses qualified staffing and approved materials for all procedures performed. It is important for you to understand that the risk of injury or death, although extremely low, is always present just as it is for 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 HELPING PAW Veterinary Services, through whomever veterinarians they may designate, to perform an operation for sexual sterilization of the animal named on the above portion of this form and or vaccinate and microchip and provide other requested services. I understand that the operation presents some hazards and that injury to or death of such an animal may conceivably result, for there is some risk in the procedure and the use of anesthetics and drugs in providing this service. I either certify that my animal has been vaccinated within one year prior to this date or waive my right to protect my animal by having it vaccinated, or request recommended vaccinations at the time of surgery. 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 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 12:00 midnight the evening prior to surgery. I understand that HELPING PAW Veterinary Services has the right to refuse service to any animal to whom surgery is deemed a health risk. I understand that HELPING PAW Veterinary Services may not perform a complete physical examination before surgery is performed. I also understand that my animal will not receive pre-operative bloodwork and waive my right to have this service performed prior to surgery at a full-service veterinarian. I understand that some factors significantly increase surgical risk, including but not limited to, pregnancy, heat, and diseases such as Feline Immunodeficiency Virus, Feline Leukemia, and heartworms. I understand that if my animal is pregnant, the pregnancy will be terminated at surgery. I understand that if my animal has an open umbilical hernia, it will be repaired at time of surgery at an additional charge. I understand that if I don’t retrieve my pet at the agreed upon time that HELPING PAW Veterinary Services will exercise its right to either turn the animal over to the nearest humane society or dispose of as deemed just and proper as allowed by the State of New York. Owners of pets left after the agreed date shall be charged a boarding fee of no less than $10 per night. I hereby release the HELPING PAW Veterinary Services, 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 them, or any of them, or file action by reason of such sterilization or attempted sterilization of such animal or any consequences related thereto. Owner/ agent hereby agrees to indemnify and hold HELPING PAW Veterinary Services 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. YOUR ANIMAL MAY HAVE AN EAR TIP PROCEDURE AND OR RECEIVE A SMALL TATTOO ON HIS/HER UNDERSIDE TO SHOW THAT HE/SHE HAS BEEN STERILIZED.Requested Feline Vaccines and Services Spay Neuter Feline Distemper Vaccine 1 year (FVRCP) $27 Rabies Vaccine 1yr $27 Felv/FIV Test $32 Treat for fleas/ticks/ear mites if necessary $19 Dental issue $15+ Hernia Repair $25-50 Elizabethan Collar (cone to prevent licking) $10 Other Other Requested Canine Vaccines and Services Spay Neuter Canine Distemper/Parvo Vaccine $27 Rabies Vaccine 1yr $27 Heart Worm Test $34 Treat for fleas/ticks/ear mites if necessary $19 Dental issue $15+ Hernia Repair $25-50 Elizabethan Collar (cone to prevent licking) $20 Microchip $38 PET GUARDIAN’S SIGNATURE acknowledging that I have read and agree with the above information* TODAY’ S DATE EmailThis field is for validation purposes and should be left unchanged.