AUTHORIZATION FOR ANESTHESIA AND/OR SURGERY
DATE OF SURGERY / PROCEDURE:
Client’s Name:
Today’s Date:
Client’s Phone #:
Client’s Address:
Pet’s Name:
Species:
Color:
Reserve a Carrier / Cage?
Procedure Requested (Spay / Neuter)
Breed:
Approximate Weight
Sex:
Age:
If yes, Size of Animal:
Rabies Vaccination?
12 wks. or more
I, the undersigned owner, or agent of the owner, of the pet identified above, certify that I am eighteen
years of age or over, and authorize the veterinarian(s) at Parke-Vermillion County Humane Society
(hereinafter PVCHS) to perform the above procedure(s). I understand that some risks always exist with
anesthesia and / or surgery and that I am encouraged to discuss any concerns I have about those risks with
the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that
any questions I have regarding the procedure(s) have been answered to my satisfaction.
*Sufficient details of the procedures to understand what will be performed.
*How fully my pet will recover and how long recovery will take.
*The most common and serious complications.
*The length and type of follow-up care and home restraint required.
*The estimate of the fees for all services.
*Any necessary payment arrangements.
While I accept that all procedures will be performed to the best of the abilities of the veterinarian(s) and
staff at PVCHS, I understand that no guarantee or warranty has been made regarding the results that may
be achieved.
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I have read and fully understand the terms and conditions set forth above.
Signature of Owner / Agent or Guardian
Cost of Surgery
$
Cost of Rabies Vaccination
$
Other Cost
$
Total Cost
$
Total Amount Paid:
$
PAID BY: Cash
Date
Date Paid:
Check No.
WIC Voucher
S/N Deposit
(attached)
Reveiving #
PVCHS STAFF NAME: _________________________________________
****IMPORTANT****
Please have your pet at the PVCHS shelter between 8:00 - 8:30 a.m. the morning of surgery. Your pet should be in
a pet carrier or cage (not cardboard). If you do not have one, please tell the staff member so we can reserve one for
you. Your pet will be ready to go home the same day as surgery after 2:00 pm. Please be here no later than 5:00
pm. If that is not possible, please tell us in the morning when you drop off your pet, or call us at (765) 492-3540.
DO NOT FEED YOUR PET AFTER 8:00 PM THE NIGHT BEFORE SURGERY.
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