Owner Name *

Co-Owner Name

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Place of Employment

Home Number

Cell Number *

Work Number

Co-Owner Work Number

Co-Owner Cell Number

Name of Previous Veterinary Clinic

Previous Veterinary Clinic Phone

Recommended by Whom?

Pet Information

Species *

Cat

Pet's Name *

Breed *

Microchip Number

Age/Date of Birth

Color

Sex

Spayed or Neutered

Do you have a second pet? *

Yes
No

Species

Cat

Pet's Name *

Breed *

Microchip Number

Age/Date of Birth

Color

Sex

Spayed or Neutered

Do you have a third pet? *

Yes
No

Species

Cat

Pet's Name *

Breed *

Microchip Number

Age/Date of Birth

Color

Sex

Spayed or Neutered

Do you have a fourth pet? *

Yes
No

Species

Cat

Pet's Name *

Breed *

Microchip Number

Age/Date of Birth

Color

Sex

I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures.

I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure. I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I understand complications are inherent to some degree in any medical procedure and/or operation. I have been given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I release Avenue of the Saints Animal Hospital from any and all liability that may arise from the procedures. I accept that my financial obligations remain regardless of the outcome. I assume financial responsibility for all services rendered and that payment is due on the date of release.

In regards to pre-anesthetic bloodwork: *

I accept the charge of $75 for the recommended pre-anesthetic bloodwork.
I decline the recommended pre-anesthetic blood test at this time and request that you proceed with anesthesia. I understand that a medical condition may exist which would be impossible to identify during a physical examination alone. I understand that my pet’s health could be at risk if such a condition goes undetected when my pet is placed under anesthesia.

In regards to post surgical pain medications: *

I accept the charge of $20 for post-operative pain medication for my pet. This medication is an injection given while under anesthesia.
I decline the recommended post-operative pain medication. I understand that my pet may be in some pain or discomfort following the procedure.

I acknowledge that my cat will be receiving a Rabies and RCP vaccine (RCP will need a booster in 3-4 week to be fully effective): *

I understand my cats will be receiving these vaccines

If your cat lives primarily outside, we recommend an ear tip (cutting the tip of the ear) to visibly indicate your cat has been altered. *

I would like an Ear tip
I decline the Ear tip

I agree to a $35 charge for the neuter, Rabies vaccine and RCP Vaccine. I understand that PAWS will be paying the remainder for these services only. Any additional procedures will be at my expense including the above selections.

I would like the following other treatments/procedures performed at my expense:

Signature *

Clear Signature

Today's Date *

Charles City

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PAWS Neuter Event Form

max 2 cats per client

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