CCHSspayneuter2016

Cat Number:  ______

Clinton County Humane Society

Spay / Neuter Clinic Release Form

Name___________________________  

Phone number where you can be reached today________________________

Address_______________________________________ City__________________________ State/ZIP_______________________

Cat’s name(s) _________________________________ Gender_____________ Age___________ Color/Markings________________

Cost: $55/cat Total____________________

I request surgery for this (these) cat(s). I understand that spaying or neutering will permanently prevent this cat from breeding. 

As the owner or keeper, I acknowledge that this (these) cat(s) is healthy, and has not eaten since 12:00am this morning. 

I understand that this cat will be tested for feline leukemia, and FIV (AIDS). If the cat tests positive for feline leukemia or FIV, this (these) cat(s) will be humanely euthanized by the attending veterinarian. I understand that “euthanasia” means to permanently put the cat to sleep humanely by way of injection. The cost to do so is included in the fee. There are no refunds for positive tests.  ___________  (initial here that you understand and agree).

I authorize these veterinary procedures: test for feline leukemia/FIV, spay/neuter, ears cleaned, vaccine administered, and any other procedures that may be deemed necessary and proper by the attending veterinarian. The cat(s) will be given deworming solution to take home and be administered. 

I understand that the veterinarians at the Clinton County Humane Society (CCHS) spay/neuter clinics DO NOT perform a complete exam. I understand that it is my responsibility to contact my veterinarian to make arrangement for a second vaccine. 

I understand this surgery requires general anesthesia. There are risks associated with anesthesia, including the risk of death of the cat. The following conditions increase the risk: not being current on vaccinations, old age (over 5 years of age), undiagnosed disease (lung, liver, kidney, etc.) or other conditions (heart, breathing, etc.). 

I understand that the above listed cat(s) are the property of CCHS after I sign this document until they are picked up after surgery. I understand that the purpose of spaying/neutering cats is to maintain as healthy conditions as possible for these animals. 

I certify that I am the owner/keeper or authorized agent of that person, for the above named cat(s) and I agree to hold harmless the CCHS or any and all of their employees/volunteers/agents including the veterinarian performing the surgery. 

I understand that this (these) cat(s) may not be completely recovered from anesthesia when I pick it up. I will be given a list of instructions for the care of the cat following surgery. If any problems should arise following surgery, I will either call my veterinarian or the veterinarian that did the surgery for assistance. 

__________________________________________ ______________

Owner/keeper/authorized agent signature Date  

Phone number ____________________________  

Emergency phone number   ____________________________

Clinton County Humane Society 

1760 Fife Avenue Wilmington, OH 45177

937-383-0703

clintoncohumanesociety@yahoo.com 
Last updated March 28, 2015