EASEL Community Assist Form

Cat spay/neuter + vaccination: $100 Dog spay/neuter + vaccination: $275 Microchip: $25 Pricing may vary depending on medical care required and will be discussed prior to surgery
First Name *
Last Name *
Email Address *
Cell Phone *
Home Telephone
Street Address *
City *
State *
Zip Code *
Special Assistance	Food Stamps SSI ADC Welfare Medicaid Other
How did you hear of us? *	Petfinder AdoptAPet Internet Search Family/Friend Staff/Volunteer Facebook/Twitter Other
Animal Name *
Description & Age of Animal *
Photo of Animal *
Animal Species *	Bird Cat Dog Ferret Guinea Pig Hamster Mouse Rabbit Rat Snake Tortoise
Breed * For Cats: DSH/Calico etc. For Dogs: Breed of animal
Coloring/Markings *
Gender *	M F Unknown
Spayed or Neutered? *	NoYes
Weight
Veterinarian Name (If Any)
Previous Vet Records
Services Needed
	Spay/Neuter + Vaccination
	Microchip
	Other
Description of Other Services Needed
All animals are expected to be healthy and have a good temperament unless noted above. Owners are required to disclose any bite history if applicable. I certify that I am the owner of, or am authorized to provide care for, said animal. I further understand that there are no written or verbal guarantees given or implied regarding the treatment of this animal. I hereby consent and authorize the EASEL Animal Rescue League (EASEL) and/or their agents to perform any necessary procedure(s). I agree to indemnify and hold EASEL and/or agent, employees and volunteers harmless from and against any and all liability arising out of the performance of any of the procedures referred to above. If a surgical procedure is indicated, by signing this consent form I am authorizing EASEL and/or its agents to administer tranquilizers, anesthetics, and/or analgesics that are deemed appropriate for my pet. I have been informed that all drugs have the potential for adverse side effects in any particular animal. The chances of such occurrence are extremely low; however, death can result in any anesthetized patient. If I neglect to pick up my pet within seven (7) days after the specified time for return and if EASEL is not notified of an alternative date within this seven day period, the pet will be considered abandoned. EASEL is given the right to place the animal up for adoption. I hereby acknowledge that I have read the above and fully understand the terms and conditions set forth. I, the undersigned, certify that the information provided is true and do hereby hold EASEL harmless in assisting with the above described animal.
Owner Signature	Clear

Thank you for submitting your form. You will be contacted by EASEL within the next 48 hours.