Owner Information

First Name *

Last Name *

Email *

Phone *

By checking this box, I consent to receive non-marketing text messages from Southern Animal Care about appointment scheduling. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Address

Street Address *

City *

State *

Country *

Postal Code *

Emergency Information

Emergency Contact Full Name *

Emergency Contact Phone Number *

Patient Information

Pet Name *

Pet Gender *

Pet Age *

Last Rabies Vaccine

Last Distemper Vaccine

Last Flea and Tick Treatment

Disclosures

Please check the following disclosures.

Authorization to Perform Surgery *

I declare that I am the owner or acting as an authorized agent of the owner of the animal described above and hereby request and authorize Southern Animal Care Clinic, through whomever veterinarian they may designate, to perform an operation for sexual sterilization of the animal listed above on this form.

Communication Policy *

I agree to be available by phone or text continuously until discharge. We will call you if your cat is ready for pickup earlier.

Indemnification / Hold Harmless *

I accept full responsibility for this procedure and indemnify (hold harmless) Southern Animal Care, Charity Inc., including its staff.

Anesthesia & Surgical Risk *

All surgeries and the use of anesthetic and drugs present some risk of complication, including injury or death, and I still agree to this.

Major Surgery Acknowledgment

The surgery performed is a major surgery, and I understand this.

Pregnant/Heat Increased Risk *

Pregnant females or those in heat may be spayed, but the animal is at increased risk.

Reasonable Precaution / Vet Discretion *

Every reasonable precaution and medical care will be exercised while the animal is a patient at our clinic. This may include the decision not to perform surgery at the veterinarian's discretion.

No Pre-Surgical Diagnostic Testing *

All cats will receive a physical exam on admittance, but no diagnostic test will be performed prior to surgery. Some medical conditions may not be detected without such testing, and I agree to this.

No Routine IV Catheter/Fluids *

Southern Animal Care does not routinely place intravenous catheters or administer intravenous fluids on surgical patients, and I agree to this.

Spay Tattoo Acknowledgment *

All female animals will have an abdominal skin tattoo to indicate they have been spayed, and I agree to this.

Pregnancy Termination Acknowledgment *

If the animal is pregnant, the pregnancy will be terminated at the time of surgery. I understand pregnancy increases the risk of serious complications, and I agree to this.

Clinic Hours / No Overnight Staff *

I am aware that Southern Animal Care closes at 3:00 pm and provides no overnight staffing, and I agree to this.

No Feeding Morning of Surgery *

I agree to not feed the animal the morning of surgery.

Owner Signature *

Clear