Pet’s Name ___________________Breed _________________Age ___________ Owner Name ________________________________________________________ Address _________________________________________________________ Phone _________________________________________________________ Please read all of the following! 1. Has your pet had any food in past 12 hours? Yes No 2. Any anesthetic procedure involves a risk, although low, of complications including, but not limited to allergic reactions, cardiac arrest and death 3. We are a Spay/Neuter clinic, any post-surgery concerns should be discussed with your Vet. We cannot cover charges incurred at other clinics. 4. There could be an additional charge to neuter an animal whose testicles have not descended, or spay an animal in heat or pregnant. 5. For the protection of your pet we can offer rabies shots, vaccinations, heart worm test and micro chipping at an additional charge. It is important that we are left with viable phone numbers! I hereby release the Miami Animal Alliance and Dr. Barber from any and all claims arising out of or connected with the performance of this operation or procedure. I am the owner of the above pet or m acting as agent* for the owner and have the authority to execute consent. I have read, Understand and agree to the information listed above. Signature __________________________________Date____________________ Cost Dogs Spay (Female) - includes Rabies if needed Dogs weighing less than 40 pounds Dogs weighing more than 40 pounds Neuter (Male) - includes Rabies if needed Dogs weighing less than 40 pounds Dogs weighing more than 40 pounds Cats Male $35 Female $45 Micro-chip Rabies Heart Worm Test Vaccine Other $20____________ $10 ____________ $15_____________ Total _______________ $5-$10_______________ _______________ Paid ________________ $50______ $60 _____ $40______ $50 _____