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Calcium chloride Injectable castration intake form
Name________________________________ Phone_________________________
Date___________
Address____________________________________________________________ _
Animal’s name______________________________
Dog___
Cat____ Breed or type ______________________________________
Colors__________
Is this pet known to be allergic to any medication Y____ N_____
Has this pet ever had a bad reaction to a sedative of any type Y ____ N____
If above answer was yes, what kind?______________________________
Age (actual) _______ Under 1 year _________ Over 1 year_______
I understand that my ____dog or ____cat will receive an intratesticular injection of calcium chloride instead
of surgery and that the injection will be administered by a veterinarian. My dog will be sedated before the
injection and will be tattooed to show that he has been altered.
The injection will render my dog permanently sterile and is expected to reduce hormones close to the level
of a castrated dog or cat.
I understand that any sedation or medical procedure carries risk. I also understand that hormone
reduction does not guarantee changes in behavior and I will not hold the tribe, humane society or
veterinarian responsible for reactions to the sedatives or if my dog retains hormones and/or
characteristic male behavior including, but not limited to, aggression toward other animals, roaming or
territorial marking. I understand that swelling will occur for two weeks following this injection.
Signed____________________________________________
Please do not write below this line- retain this form as proof of sterilization and rabies vaccination of your pet
Body condition: (poor) 1 2 3 4 5 6 7 8 9 (obese)
Weight_______ Temp _______ Pulse ______ Resp. _______
CRT_________ MM____________
Sedation ______________ Vol. ______ Pain mngment ________ Vol ____
Right testicle ____mm
Volume CaCl ________________ 20 g needle___
Left testicle _____mm
Volume CaCl ________________ 20 g needle ___
Rabies administered concurrently Y___ N___
Vaccine administered concurrently Y___ N ___
Deworming administered concurrently Y__ N__ Type___________ Vol_____
Tattoo Y___ N___
Veterinarian _______________________________ State_____________
Veterinarian signature_________________________________________
Comments __________________________________________________
Organization name, address and phone number goes here.
Rabies Certificate
Date_________
Mfr. _________
Product Exp. __________
1___ 3___ year vaccine
(check one)
Serial # ______________
DVM lic._________
State ___________