Spay/Neuter Consent Form

First Name *

Last Name *

Email address *

Mobile Phone *

Alternate Phone Number

The address should be the location where the pet lives. You do NOT need to live in Barrow County to use our clinic. We may request proof of address at check in. A driver's license or utility bill is accepted as proof.

Address *

City *

State *

Zip Code *

County *

Banks
Barrow
Jackson
other

Animal's Name *

Sex *

Female
Male

Age / Date of Birth *

Species *

Dog
Cat

Breed or mix (if known)

Does this pet have a current rabies vaccination? *

Which vet/clinic gave the rabies vaccination (proof required)? *

Services for Dogs *

Services for Cats *

Do you have another pet with an appt today? *

Second Animal's Name *

Second Animal's Sex *

Female
Male

Age / Date of Birth *

Second Animal's Species *

Dog
Cat

Breed or mix (if known)

Does this pet have a current rabies vaccination (proof required)? *

Which vet/clinic gave the rabies vaccination? *

Services for Dogs (Pet 2) *

Services for Cats (Pet 2) *

Do you have another pet with an appt today? *

Third Animal's Name *

Third Animal's Sex *

Female
Male

Age / Date of Birth *

Third Animal's Species *

Dog
Cat

Breed or mix (if known)

Does this pet have a current rabies vaccination? *

Which vet/clinic gave the rabies vaccination (proof required)? *

Services for Dogs (Pet 3) *

Services for Cats (Pet 3) *

Do you have another pet with an appt today? *

Fourth Animal's Name *

Fourth Animal's Sex *

Female
Male

Age / Date of Birth *

Fourth Animal's Species *

Dog
Cat

Breed or mix (if known)

Does this pet have a current rabies vaccination? *

Which vet/clinic gave the rabies vaccination (proof required)? *

Services for Dogs (Pet 4) *

Services for Cats (Pet 4) *

Do you have another pet with an appt today? *

Fifth Animal's Name *

Fifth Animal's Sex *

Female
Male

Age / Date of Birth *

Fifth Animal's Species *

Dog
Cat

Breed or mix (if known)

Does this pet have a current rabies vaccination? *

Which vet/clinic gave the rabies vaccination (proof required)? *

Services for Dogs (Pet 5) *

Services for Cats (Pet 5) *

Do you have another pet with an appt today? *

Sixth Animal's Name *

Sixth Animal's Sex *

Female
Male

Age / Date of Birth *

Sixth Animal's Species *

Dog
Cat

Does this pet have a current rabies vaccination? *

Which vet/clinic gave the rabies vaccination (proof required)? *

Services for Dogs (Pet 6) *

Services for Cats (Pet 6) *

Do you have another pet with an appt today? *

Seventh Animal's Name *

Seventh Animal's Sex *

Female
Male

Age / Date of Birth *

Seventh Animal's Species *

Dog
Cat

Does this pet have a current rabies vaccination? *

Which vet/clinic gave the rabies vaccination (proof required)? *

Services for Dogs (Pet 7) *

Services for Cats (Pet 7) *

Do you have another pet with an appt today? *

Eighth Animal's Name *

Eighth Animal's Sex *

Female
Male

Age / Date of Birth *

Eighth Animal's Species *

Dog
Cat

Does this pet have a current rabies vaccination? *

Which vet/clinic gave the rabies vaccination (proof required)? *

Services for Dogs (Pet 8) *

Services for Cats (Pet 8) *

Do you have another pet with an appt today? *

Ninth Animal's Name *

Ninth Animal's Sex *

Female
Male

Age / Date of Birth *

Ninth Animal's Species *

Dog
Cat

Does this pet have a current rabies vaccination? *

Which vet/clinic gave the rabies vaccination (proof required)? *

Services for Dogs (Pet 9) *

Services for Cats (Pet 9) *

Do you have another pet with an appt today? *

Tenth Animal's Name *

Tenth Animal's Sex *

Female
Male

Age / Date of Birth *

Tenth Animal's Species *

Dog
Cat

Does this pet have a current rabies vaccination? *

Which vet/clinic gave the rabies vaccination (proof required)? *

Services for Dogs (Pet 10) *

Services for Cats (Pet 10) *

I would like to make a tax deductible donation! *

Donation amount

$5
$10
$20
other

Additional Information

I understand that there are risks associated with anesthesia and surgery and that complications including death may arise during or after the procedure. By signing, I agree that I am the owner or authorized agent of the animal described above and that I have the authority to offer consent for surgery. I hereby release Leftover Pets Inc. and its agents, including Dr. Amber Polvere, from liability associated with surgery or boarding at the spay/neuter service. I understand that I will not be contacted if my animal is discovered to be pregnant and that the spay procedure will be completed. For male animals with retained testicle(s), castration will be performed and the cryptorchid fee will be charged with no guarantee that the retained testicle(s) can be located and removed. I understand that the service does not require complete medical records on animals presented for surgery and that all animals presented for surgery may not be healthy. Cats may be given an injectable pain medicine which is used off label. This medicine is made at a licensed compounding pharmacy. You must tell us before surgery if you do not want your pet to receive this medication. I understand that my animal may come in contact with an infectious agent as a result of entering the clinic and that unvaccinated animals are at a greater risk for developing disease. Animals older than 5 years and those with health conditions such as respiratory or skin infections, obesity, pregnancy, or heartworm disease are at a greater risk for developing complications during and after the procedure

Date *

Signature *