ANIMAL SHELTER SOCIETY, INC. Veterinary Facility License # Fac 8 Spay/Neuter Packet Please complete this form and remit with payment made payable to: Animal Shelter Society, Inc. 1430 Newark Road Zanesville, Ohio 43701 Telephone: 740-452-1077 Once payment is received you will be contacted to schedule your pet’s surgery. Name: _______________________________________________________ Address: ______________________________________________________ City: ___________________________ State: ____________ Zip: _________ Telephone: (Daytime) ________________ (Evening) ____________________ Email: ________________________________________________________ Pet’s Name: _______________________ Approximate Age: _____________ Dog: __________ Cat: ___________ Male: ________Female:_____________ Breed Type: ______________ Color: _______________ Coat: Long or Short Canines - Proof of current Parvo/Distemper combo and Bordetella vaccination required at least 7 days prior to surgery. Rabies vaccination is required by Ohio State Law for dogs over 4 months of age and may be given at the time of surgery. Felines - Proof of current HCPCh (RCCP) vaccination is required prior to surgery. Additionally, rabies vaccination, leukemia test and leukemia vaccination are strongly recommended for outdoor cats. If your pet has fleas, you will be charged $8.00 for a capstar. Animal Shelter Society, Inc Veterinary Facility Patient Check-in Information Owner's Name____________________________Patient's Name_____________________ Telephone number where we can reach you today :(______) _________________ How long have you owned this animal? __________________________________ Has your pet displayed any of the following in the last 2 weeks: (check if yes) Sneezing_____ Coughing_______ Vomiting______ Diarrhea_______ Has your pet ever had a seizure? Yes_____ No____ If yes, explain: ____________________________________ If your pet is female: When was her last heat cycle? ______________ Unsure_______ Has she had any litters? Yes_____ No ____ If so, when was last time? ________ Is your pet pregnant? Yes_____ No____ Could be____ Has your pet had any previous (Please explain)? Illness? _____________________________________________ Injuries? ____________________________________________ Surgery? ____________________________________________ Drug or vaccine reaction? _______________________________ Is your pet on any long-term medication? Yes___ No ___ If yes, list all _______________________________ Has your pet been given any medication in the last month? Yes___ No ___ If yes, list type and why it was given_______________________________________ Has your pet been treated or dipped for fleas/ticks in the last month? Yes__ No__ If yes, what product was used? _________________________ When was the last time your pet was: Heartworm tested? ___________ Not tested ______ Unsure if has been____ Leukemia/FIV tested? _________ Not tested ______ Unsure if has been ____ Is your pet on monthly heartworm prevention? Yes____ No _______ If yes, what type? Heartguard Interceptor/Sentinel Revolution Iverheart Client/Agent Signature________________________________ Date: ___________________ The Animal Shelter Society, Inc. Surgery Release of Liability THIS IS A GENERAL RELEASE OF ALL CLAIMS BY PET OWNERS. The agreement made on __________________________by and between_________________________ Date Owner’s Name hereafter referred to as “Owner” and the Animal Shelter Society, Inc., of Zanesville, Ohio, hereafter referred to as “Shelter”, is a release whereby the owner extinguishes his/her rights and claims against the “Shelter”, shelter employees and veterinarian as herein enumerated. Now, therefore, with intent to be legally bound and in consideration of the release performing certain surgical services for the owner. The owner agrees as follows: 1.) The owner, on behalf of himself, his heirs, executors, administrators, and assigns hereby fully releases and discharges release and its assigns and successors from all rights, claims and actions which the owner and his above mentioned successors now have or may have after the signing of this agreement against the shelter and its above mentioned successors arising out of a surgical procedure of any animal or any pet of the owner. 2.) This release is intended by the parties to release all injuries, damages or losses to the owner whether known, unknown, foreseen, or unforeseen, including death, termination of pregnancy, or complications resulting from a surgery, also which owner may have against the shelter or the shelter’s on staff veterinarian. The owner further acknowledges that the shelter shall not be responsible for services rendered by any veterinarian, before or after the surgery. The owner understands and acknowledges the significance and consequences such specific intention to release all claims and hereby assumes full responsibility for any injuries, damages or losses that he/she may incur from the above mentioned services provided. 3.) This release is freely and voluntarily executed by the owner after having been apprised of all relevant information and data. The owner in executing this release does not rely on any inducements, promises, or representations made by the shelter, its representatives, or employees. 4.) The owner has read this release and had the terms used herein, in the consequences thereof fully explained to him/her by the employees, or a member of the Board of Trustees of the Animal Shelter Society, Inc. Signed Owner: ___________________________________________________________ Signed Shelter Employee: _____________________________________________ ANIMAL SHELTER SOCIETY, INC. VETERINARY FACILITY License # Fac 8 INSTRUCTIONS BEFORE THE SURGERY Food and Water: Do not give your cat or dog food after 10 P.M. the night before surgery and do not give it any food or water the morning of surgery. Prescription Medication: If your pet is on any medication other than heartworm pills ask your veterinarian or call us prior to the surgery date to determine if the medication should be given the morning of the procedure. Nursing Animals: Lactating animals should not nurse for at least 2 weeks before the day of surgery. The animal’s litter should be between 6 and 8 weeks of age and eating and drinking on their own prior to spaying the mother. Pediatric Surgeries: Pets must be at least 4 months of age for spay and neuter. If your pet is less than 4 months, you must bring him/her back at a later time. No Exceptions. Heartworm Prevention: Heartworm prevention should be administered as normal, regardless of the surgery date. Restraining Your Pet: All dogs must be on a leash and cats must be in a pet carrier. An Appointment has been scheduled for your pet’s spay/neuter operation for: _______________________________________ Your pet will need to arrive at the Animal Shelter between 8:00 and 8:30A.M. You will need to report at the front desk through the main entrance. All pets must be picked up between 4:15 and 5:00 P.M. the day of the surgery. Thank you and if you have any questions please contact the Animal Shelter at: 740-452-1077 If your pet has fleas, it will be given a Capstar and you will be charged $8.00 when you pick up your pet. The Animal Shelter Society Inc. 1430 Newark Road Zanesville, OH 43701 Phone: (740) 452-1077 Post Surgery Instructions Your Pet will be excited upon seeing you which calls for special attention. As your pet leaves the shelter he will at once be confronted with your welcome, a car ride which may give rise to a bit of motion sickness, the overly stimulated sights, sounds, and smells of home, and a possible surplus of food and water. Too often the animal leaps and races, gulps food and water beyond its capacity, and ends up with a case of nervous vomiting or diarrhea. In order to avoid these conditions and to provide for the comfort of your pet and you peace of mind, you will find these suggestions helpful: Proper restraint: To protect your pet when leaving the shelter, proper restraint (leash or carrier) is important. Sudden lunging or jumping might result in your pet getting loose or worse; result in injury if it is recovering from surgery. Limit food & water intake: Excessive gulping of food and water can lead to stomach upset. Give your pet small amounts of food and water until it had adjusted to normal home life. Control exercise: To show his happiness at being home, your pet will want to run and jump. It is best to discourage excitement by restricting its play. Following surgery, outdoor exercise during the first 10 days should be restricted to walking on a leash. Stairs: Keep pets away from stairs until fully awake to avoid falls. Chewing & licking: DO NOT allow your pet to lick or chew at its sutures or surgery site. Purchase an E-Collar. Cat surgery: Your cat should have shredded paper litter for at least 10 days following surgery. Do not let your cat jump from counters or other furniture. Medicine time: Your pet may be sent home with medication. If medication is sent home for your pet, it is important that you administer on time and in the amounts directed. Bath time: DO NOT bath your pet for at least 10 days after the date of surgery. The date of surgery can be found on the health record provided for you at the time your pet leaves the hospital. Suture removal: If your pet has sutures they need to be removed two weeks from the surgery date. This information can be found on the health record provided at time of departure from the shelter. Puppy love: Although your pet has just been neutered doesn’t mean that a neutered male will not try to mount a female, or male dogs may try to mount a spayed female. Do not let this happen for this could cause serious injury or even result in death if the pet is not fully healed inside and out. Keep your pet on a leash at all times when not in the house. If you will follow these simple rules, you will best protect your pet’s well being and his homecoming will be a pleasant experience for everyone. Thank you for having your pet spayed or neutered and helping to keep the pet population under control. Owner Signature:_________________________________________________ Date_______/______/_____ ANIMAL SHELTER CANINE REGISTRATION FORM SERVICES Dog Spay: Up to 60 Pounds Dog Neuter: 95.00_____ Up to 60 Pounds 75.00_____ Any Canine over 60 pounds will require price Quote by Veterinarian_________LBS $________ In Heat Minimum 20.00__________ (Additional fee possible) Pregnant Minimum 35.00 _________ (Additional fee possible) Crypt orchid Males (Retained Testicles) Minimum 30.00__________ (Additional fee possible) Umbilical Hernia Repair (Protruding Belly Button) Minimum 20.00__________ (Additional fee possible) Note: There is $25.00 sedation/anesthesia fee for pets that are found to be already spayed/neutered following sedation and without surgical exploratory. Vaccinations: (The following prices are available only when receiving spay/neuter services) DAPPv only DAPPv+L4 only Rabies only Bordetella (Kennel cough) DAPPv, DAPPv +L4, Rabies & Bordetella Package 11.00 11.00 11.00 Ear Cytology 8.00 Heartworm Test 15.00 Capstar Microchip 8.00 20.00 11.00 25.00 Misc.__________________________ TOTAL COLLECTED: __________________ DATE OF SURGERY: ___________________ RECEIPT NUMBER: ___________________ All pet owners are required to provide proof of current 5-way, rabies and bordetella vaccinations for your pet. Bordetella should be administered at least 7 days prior to surgery. Other vaccinations may be administered the day of the surgery. ANIMAL SHELTER FELINE REGISTRATION FORM SERVICES Feline Spay 60.00_______ Feline Neuter 40.00_______ Pregnant/In Heat Minimum 20.00________ (Additional fee possible) Cryptorchid Males (Retained Testicles) Minimum 30.00________ (Additional fee possible) Umbilical Hernia Repair (Protruding Belly Button) Minimum 20.00 ________(Additional fee possible) Declaw Only (front feet Only) < 10 lb 105.00 ________ >10 lb 125.00 ________ Note: There is $25.00 sedation/anesthesia fee for pets that are found to be already spayed/neutered following sedation and without surgical exploratory. Vaccinations: (The following prices are available only when receiving spay/neuter services) HCPCh (RCCP) Rabies Leukemia Vaccination Only (Must have proof of prior test or vaccination within the year) FeLV Test & Leukemia Vac (<6 months) FeLV/FIV Test & Leukemia Vac (>6 months) FeLV Test only (<6months) FeLV/FIV combo test (> 6months) 11.00 _______ 11.00_______ 11.00_______ Capstar Ear Cytology Microchip 25.00_______ 35.00_______ 20.00_______ 25.00_______ Misc.______________________________________ TOTAL COLLECTED: __________________ DATE OF SURGERY: ___________________ RECEIPT NUMBER: ___________________ Cats are required to have a HCPCh (RCCP) vaccination. 8.00 8.00 20.00 ANIMAL SHELTER DENTAL REGISTRATION FORM Dental prophylaxis and treatment Dental add on with spay or neuter: Cats- 35.00 _________ Dogs under 40 lb – 45.00 _________ Dogs over 40 lb – 60.00 _________ Dental only (no spay or neuter) Cats- 55.00 Dogs under 40 lb- 80.00 _________ Dogs over 40 lb- 100.00 _________ Tooth extractions- 6.00 to 20.00 EACH, based on size of tooth and time required for extraction. Additional costs **** Pets will be sent home with antibiotics if current infection or risk of postdental infection is found. The cost will be based on the size of the pet and the duration of antibiotics required (= the severity of infection). Cost will range from $15.00 to $30.00 *****Pain medicine will be sent home if significant tooth extractions are performed. Cost will be $10.00 to $20.00 *OTHER: Rabbit spay 95.00_______ Rabbit neuter 75.00_______ *Additional charges may apply if in heat or pregnant.