Spay-and-Neuter

Owner Name: Date:

Contact Phone: E-mail:

Address:

City: State: Zip Code:

Owner Yearly Income:

Under $6,000 a year $6,000 to $12,000 $12,000 to $18,000 $18,000 to $25,000 $25,000 to $40,000

Pet's Name: Pet is kept: Indoors Outdoors Both

Type of animal Sex Breed Colors

Age How long owned? Vaccines Current? Heartworm Preventative?

Does your pet have any known allergies to medication or anesthesia?

If yes, what kind?

Approximate Weight of Pet:

Is your pet dog aggressive? Is your pet human aggressive?

Is your dog leash trained? Do you have a crate for your pet that you can bring to the clinic?

Waiver of Consent: Please print your name below to give us permission to spay/neuter your pet. You will still need to sign the day of the clinic in person. I the owner understand that all anesthesia and surgery carries risk and that unforeseen conditions may be present that cannot be detected without blood screening and which can increase the risks of abnormal bleeding or death. I understand that animals of advanced age or that have never been vaccinated, can carry increased risks. I agree not to hold the participating veterinarians or their representatives, the participating humane organization, volunteers or the facility liable for damages. If the veterinarian deems that the animal is not in condition to undergo surgery, surgery will not be performed. I certify that all information regarding my animal and income is correct and true to the best of my knowledge.

Owner Signature(print please)

Owner Signature(sign at clinic)

Pound Pals Representative Signature

Date: