Name *

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Email *

Address *

Address Line 1

Address Line 2

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Pet’s Name *

Species *

Cat
Dog

Breed *

Sex *

Male
Female

Age *

Colors/Markings *

Current Medications/Supplements *

Dogwood Park Animal Clinic 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 Dogwood Park Animal Clinic, through whomever veterinarians they may designate, to perform an operation for sexual sterilization of the animal named on the above portion of this form. Please initial below that you have read and understood the following. If you do not understand or have questions please 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 may conceivably 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 I cannot show proof of vaccination, my pet will be vaccinated against rabies and I will be responsible for the costs. *

I understand that there are inherent risks of exposing my pet to other animals if they are not current on their vaccines. 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 understand the inherent risks of failing to maintain current heartworm preventative 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 midnight the night prior to surgery. *

I understand that Dogwood Park Animal Clinic has the right to refuse service to any animal to whom surgery is deemed a health risk. *

I understand that it is my responsibility to alert Dogwood Park Animal Clinic’s staff of any health conditions or concerns I have regarding my pet. *

If your pet is seven years old or older, our veterinarians recommend pre-operative blood work. I authorize Dogwood Park to perform these added procedures and understand there will be additional costs incurred as a result. *

If your pet is seven years old or older, our veterinarians require placement of an IV catheter and receipt of IV fluids. I authorize Dogwood Park to perform these added procedures and understand there will be additional costs incurred as a result. *

I understand that some factors significantly increase surgical risk, including but not limited to diseases such as Feline 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. *

I understand that if my animal is pregnant, the pregnancy will be terminated during surgery. I understand that pregnancy increases the risk of surgery and that there will be an extra charge for performing surgery on animals that are pregnant. *

I understand that if my animal has an umbilical hernia, has an inguinal hernia, is cryptorchid, or needs retained deciduous teeth removed it will be repaired at time of surgery at an additional charge. *

I understand that if my animal is found to have fleas, ticks, tapeworms, or other parasites, which have the potential to 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 surgery under the doctor’s discretion. *

I certify that I have been provided an estimate for the cost of the procedure/s and I agree to pay all fees associated with this procedure. *

I understand that if I don’t retrieve my pet at the agreed upon time that Dogwood Park Animal Clinic 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 Georgia. Owners of pets left after the agreed date or time shall be charged a boarding fee of no less than $75 per night. *

I hereby release the Dogwood Park Animal Clinic, MV Veterinary Services LLC, 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 Dogwood Park Animal Clinic/MV Veterinary Services LLC 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 pet’s 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 pet’s current health status? If yes, please describe here. *

Yes
No

Requested Vaccines and Services *

ADDITIONAL PROCEDURE(S) TO BE PERFORMED (NOT MARKED ABOVE)

Date *

Spay/Neuter Surgical Admission Form

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