Furry Friends Community Spay Clinic
Surgical Consent Form
Date:_______________ Owner Name: ________________________________
Address: __________________________________________________ City__________________Zip:____________
Surgery Day Phone: _________________ Home Phone: ________________
PLEASE READ AND INITIAL BELOW
_____ Any anesthetic and surgical procedure carries inherent risks of complications. While rare, serious complications including but not limited to: infection, bleeding, allergic reaction, cardiac arrest, and death do sometimes occur. I accept this risk, and understand that I am responsible for the costs of treating any complications.
_____ The risk of serious complications can be minimized (but not eliminated), by certain services that we cannot provide (such as pre-anesthetic bloodwork, placement of IV catheters, and fluid administration). If you wish to receive these additional services, please bring your pet to a veterinarian that offers these services.
_____ I certify that this adult pet(s) has not eaten any solid food since midnight last night, or if not, I accept the increased risk of complications that can arise from aspiration while under anesthesia.
_____ Pregnancy, being in heat, excessive milk, obesity, previous C-sections, or retained testicles may complicate surgery, extend recovery, require additional after care, and additional charges may apply. *Charges determined by the doctor and based on additional time and supplies required.
_____ If my pet rips, tears, licks, or chews open his/her incision following surgery, I will be responsible for all charges resulting from additional surgery, hospitalization, medications, etc. *E-collars are available at any pet supply store.
CONSENT FOR SURGICAL STERILIZATION
I, being of legal age and responsible for the animal(s) described, have the authority to grant Furry Friends Community Spay Clinic, and its staff members, or volunteers my consent to perform sterilization surgery.
I understand that modern techniques and trained staff will be used to care for all animals and reasonable precautions will be used against injury, escape or death of the animal(s). I understand that risk always exists with anesthesia and/or surgery.
I will hold harmless Furry Friends Community Spay Clinic, the veterinarian, the veterinary technician, and volunteers, should anything happen to the animal(s) described below.
I understand that the Furry Friends Community Spay Clinic is not a full-service veterinary clinic and any procedures and care over and above the spaying or neutering procedure must be addressed by a full-service veterinary clinic at my expense. Further, if an emergency arises and Furry Friends Community Spay Clinic is unable to perform the necessary emergency procedure, the clinic personnel may transport the animal(s) to a clinic with such capabilities with notification to the owner.
I understand that all animals must be picked up from the clinic at the end of the surgery day. I understand that after 24 hours animals will be considered abandoned. I understand that if any animal has been so abandoned, I relinquish all ownership rights and I will be responsible for any and all medical costs and boarding expense.
Dog / Cat M / F Pet name: ________________________ Age:______________________
Breed:_________________________ Color: __________ Weight:______
Distemper Vaccine FREE Distemper Vaccine FREE
Rabies Vaccine FREE Rabies Vaccine FREE
Flea/Tick Prevention FREE Flea/Tick Prevention FREE
Microchip with surgery $5 Microchip with surgery $5
Microchip without surgery $15 Microchip without surgery $15
Heartworm test $10 FeLv test $15
Nail trim $5 FeLv/FIV test $20
Nail trim $5
I have read and understand this release and agree to all terms.
Signature: _________________________________________________ Date: ______________________
Furry Friends Community Spay Clinic <> 1209 Grand Avenue <> West Des Moines, IA 50265