Fixing the Boro SNIP Clinic

Spay/Neuter Surgery Consent and Release Form

Owner/Pet Information

Owner Name

Pet Name(s)

Date of Surgery

Address

City

Zip

Services Rendered

Additional Notes

Terms

Please read the following terms carefully to ensure you understand. Select each checkbox to confirm you have read and agree to the terms.

	I understand that the operation I have elected presents some hazards, and that injury to and post-operative infection in, or death of, the animal may conceivably result, for there is some inherent risk in the procedure and in the use of anesthetics and drugs provided for the procedure, as well as any vaccines used. I understand that general anesthesia will be administered to the animal for surgery. I understand and accept these risks to the animal.
	I understand the inherent risks of failing to maintain current vaccinations and waive all claims arising out of, or connected with, the performance of this operation due to such failure. I understand, in particular, that if the animal develops kennel cough or other upper respiratory infections after surgery, I am responsible for treatment at my own cost.
	I understand the animal will receive a small tattoo on his/her underside to show that he/she has been sterilized.
	I acknowledge that I will receive the Post-Surgical Home Care Instructions and will provide proper post-surgery monitoring and care for the animal including, but not limited to, the Instructions.
	I am over the age of 18 and the lawful owner (or the owner's authorized representative) of the animal described on the front of this form.

Spay/Neuter Surgery and/or Vaccinations

I agree to be bound by the following terms and conditions:

Authorization for Procedure. To the best of my knowledge, my animal is in good health and is able to undergo the medical procedure. I have informed Fixing the Boro of any known pre-existing health concerns that my animal has. I hereby authorize Fixing the Boro to receive, treat, prescribe, transport, care for and house my animal and to perform such anesthetic, medical, surgical and therapeutic procedures as indicated above.
Acknowledgement of Risks. I understand that, as with any instance in which my animal is outside the home, my animal may be exposed to other animals that have not been appropriately vaccinated or that have been exposed to contagions and illnesses. I also understand that local and/or general anesthesia will be administered to my animal and a medical procedure will be performed on my animal; this involves uncertainty and risks to my animal. I understand and acknowledge this information and I assume all risks associated with the anesthesia and medical procedure, including any adverse effects, illness or death of my animal. If my animal is receiving a spay/neuter procedure, I understand that the animal may receive a small tattoo on his/her underside to show that it has been sterilized. I understand that a brief pre-surgical exam (or visual exam of fractious animals) will be performed, and I also understand that the attending veterinarian performing the medical procedure has the right to decline to perform any procedure on any animal for any reason. I understand the animal will not receive pre-op bloodwork. If I choose for the animal to have such bloodwork done, I understand it must be performed at a full-service veterinary clinic. If, in the course of treatment or during the procedure, the animal is found to be pregnant, the pregnancy will automatically be terminated. If any other condition is discovered that requires medical attention or an additional procedure(s), we will call the owner or authorized representative at the phone listed on this form. If we are unable to reach the owner or authorized representative in a timely manner, the attending veterinarian may in his/her absolute and sole discretion, perform such procedure(s) without seeking additional authorization or consent from the owner or authorized representative. I consent to any such additional procedure(s) and agree to take full responsibility, financial and otherwise, if the animal becomes ill.
Post-Procedure. I agree to contact my own veterinarian with any questions that arise following the medical procedure about my animal's health related or unrelated to the medical procedure. If I suspect that the animal has a postoperative complication caused directly by the procedure, I agree to follow the Post-Surgical Home Care Instructions or any other instructions received by me from Fixing the Boro.
Animal Pickup. I understand that all animals shall be picked up from the clinic by me, or by someone authorized on my behalf, at the time designated by the clinic staff, on the same day as spay/neuter procedures or vaccinations are performed. If my animal is not picked up at the designated time on that day, I understand that Fixing the Boro shall have no obligation to wait for or contact me, and that my animal will be considered to be abandoned by me.
If the animal remains at Fixing the Boro after the close of business day on the date of surgery, I understand that Fixing the Boro will make an attempt to contact me but will also report the case as abandonment to the Bulloch County Animal Shelter and will request the shelter to pick up the animal the following morning.
General Release and Waiver. I understand that Fixing the Boro will rely on my representations made in this agreement. I know that this is a legal document and I promise that to the best of my knowledge everything that I have said is true. No one has forced me to sign this document. I am willing to sign this waiver and release agreement because Fixing the Boro will provide the spay, neuter or vaccination as I requested, and I am consenting to the medical procedures being performed on the animals and all related activities of any kind and acknowledge that I understand that all risk, whether known or unknown, is expressly assumed by me and all claims, whether known or unknown, are expressly waived in advance. On behalf of myself, my heirs, personal representatives and assigns, I hereby release, discharge, indemnify and hold harmless, Fixing the Boro and its directors, officers, employees, volunteers and agents from any claims, causes of action and demands of any nature, whether known or unknown, arising out of or in connection with the medical procedure performed on the animals and all related activities of any kind including without limitation other treatment and care given to the animals or the housing of the animals. By signing this Waiver and Release Agreement, I am consenting to the medical procedures being performed on my animal and all related activities of any kind and acknowledge that I understand that all risk, whether known or unknown, is expressly assumed by me and all claims, whether known or unknown, are expressly waived in advance.
I also understand and agree to permit Fixing the Boro to use my name and pictures of me and/or my animal for publicity or promotional purposes without liability or obligation to me.

By signing, I acknowledge that I have read, understood and agree to all the terms listed above and on the reserve side and confirm that all the information given on this form is correct.

Signature

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