EmailMe Form - Canine Spay/Neuter Registration & Liability

Today's Date: *

MM / DD / YYYY

Owner Information:

Name: *

First Last

Primary Phone: *

### - ### - ####

Physical Address: *

Street Address City State / Province / Region Postal / Zip Code

Email: *

Person to contact if you cannot be reached:

Name *

Phone Number: *

### - ### - ####

SERVICE TO BE PROVIDED:

Animal Name: *

Gender *

Male

Female

Age: *

Months or Years *

Months

Years

Weight: *

Primary Breed: *

Primary Color *

Secondary Color

Please Select Service: *

Canine Neuter (male) $150.00

Canine Spay (female) $200.00

Additional Costs:

In Heat $20.00

Pregnant $20.00

Umbilical Hernia $15.00

Over 70lbs. $20.00

*

I understand that if any of the above is noted during surgery, I will be charged the additional cost(s).

*

I understand that all dogs will leave in an e-collar (cone), which is provided with the service.

Cryptorchids (the absence of at least 1 testical from scrotum) are not accepted. *

Cryptorchids (the absence of at least 1 testical from scrotum). I understand that if the dog is male, I must contact LPCHS before my appointment to confirm that there is no cryptorchid, and that lack of confirmation may result in refusal of service.

Vaccination Requests:

Please select all vaccinations or services you would like your pet to receive.

DA2PPV (Canine Booster-Distemper, Adenovirus Type 2, Para Influenza and Parvovirus) $35.00

Bordetella (Kennel Cough) $35.00

Rabies Vaccine $35.00

Heartworm Test $50.00

De-wormer for Tapeworms $35.00

Microchip $50.00

Nail Trim $25.00 (without a muzzle)

Nail Trim $35.00 (with a muzzle)

E-Collar (Included Upon Request)

Has you pet ever had a bad reaction to a vaccine? *

Yes

No

Is your pet on any medication at this time? *

Yes

No

If yes, what?

LIABILITY WAIVER:

Owners Name: *

Primary Phone: *

### - ### - ####

Physical Address: *

Street Address City State / Province / Region Postal / Zip Code

LPCHS uses qualified staff and approved materials for all procedures performed. It is important for you to understand that the risk of injury or death is always present. Carefully read and understand the following before signing your name.

Acting as guardian of the pet named above, I hereby authorize authorize LPCHS, through veterinarians designated by LPCHS, to perform an operation for reproductive sterilization.

*

I certify that my pet is in good health and has had no food since 12:00 a.m. on the evening prior to surgery.

*

I understand that LPCHS has the right to refuse service to any animal for who surgery is deemed a health risk.

*

I understand if my animal is deemed to be older than stated above, LPCHS has the right to refuse surgery.

*

I understand that the operation presents some hazards and that injury or death may be a result, for there is some risk in the procedure and the use of anesthetics and drugs in providing this service.

*

I understand that my animal may be exposed to a contagious disease during the clinic and if my animal is not fully vaccinated and contracts any illness I am responsible for seeking out and paying for veterinary care.

*

I understand that some factors significantly increase surgical risk, including but not limited to: pregnancy, heat, advanced age, and disease such as FIV, FeLV and heartworms.

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I understand that serious complications can occur as a result of this surgery, including, but not limited to: bleeding, nerve damage, bowel or urinary problems, blood clots and heart attack, allergic or other reactions to drugs or anesthetics.

*

I understand that individual pets may respond differently to anesthesia and because of the stress of a surgical procedure, unexpected reactions may occur under anesthesia. Some complications are unpredictable and in rare cases, cause death.

*

I understand that during these procedures, unforeseen conditions may occur, require a change of the procedures listed above & I give my consent for the performance of such procedures as deemed necessary in the judgment of the veterinarians.

*

I understand that my animal will not recieve pre-operative blood work and waive my right to have this service performed prior to surgery. If you would like to have pre-operative blood work, there will be a $100.00 fee.

*

I understand that if I don't retrieve my pet at the agreed upon time, LPCHS will exercise the right to adopt the pet out after five days of no contact, authorized by Colorado Law.

*

I hereby release and forever discharge LPCHS, its employees, agents, representatives, Officers & Directors from any and all actions, claims or costs on account of or in any way arising from the surgical services authorized by this Release.

*

I understand that pick up time for my animal is no later than 5pm on the same day as surgery. If I fail to retrieve my animal by the agreed upon time, LPCHS will charge $100.00 for a hospitalization fee per pet.

*

I certify that my pet has/have not harmed or shown aggressive or threatening behavior towards any person or animal. If LPCHS staff needs to take extra precautions before/after your pets medical procedure (muzzle, squeeze cage ect.) is a $50.00 fee

*

I hereby confirm that I (owner) am over 18 years of age.

- I have been informed and understand that there are risks inherent in any type of surgery and that in some cases, my pet may die or suffer serious effects during or after surgery. Knowing these risks and the dangers associated with surgery, *

I hereby release and discharge LPCHS, and it's agents from any and all actions, claims, damages, loss of services, expenses and compensation on account of the surgical services to be performed and authorized by this form.

Payment is due in full when appointment is scheduled. Appointment(s) will not be scheduled if payment has not received.

I have a tribal ID OR Medicaid Card and would like to take advantage of the reduced cost spay/neuter ($40) supported by Colorado Pet Overpopulation Fund.

I have a voucher for spay/neuter from Street Dog Coalition

*

I understand payment is due in full when my pet's appointment is scheduled.

*

I understand I understand that I am required to provide 24 hours notice when canceling and re-scheduling appointments to avoid being charged. Same day and "no show" appointments are not eligible for a refund.

*

I understand a team member will call me to schedule an appointment and process my payment.

Signature

If using a computer or labtop, use mouse to add signature. If using tablet, sign with finger.

Clear

Upload valid drivers license or government ID *

Upload proof of residence if not shown on photo ID.

Upload your tribal ID or Medicaid card if taking advantage of our $40 spay/neuter program supported by Colorado Pet Overpopulation Fund.