Patient/Client Information - RAL

1 11401 International Dr Richmond VA 23236 p: (725) f: See Prices on Page 2 See Prices on Page 2 Patient/Client Information Program Code:_____ Owner/Responsible Agent Name (Please Print) _____Date___/____/_____ Address:_____ City _____ State_____ Zip:_____ Email: _____ Phone (Reached Immediately):(C) _____ (H)_____(ALT)_____ Animal Name:_____Breed:_____ Species: Feline Canine Age:_____ Color:_____ Sex: M - Neuter F -Spay Donations: The Loving Spay+Neuter Clinic is a non-profit 501(c)(3) organization that relies on donations from the public.

2 The average cost of each surgery is $120. If you would like to make a tax deductible donation in addition to prices listed on the reverse side to the Loving Spay + Neuter Clinic, please indicate the amount below. Thank you! _____$100 _____$75 _____$50 _____ $25 _____ $15 _____$10 _____ $5 _____Other PET HISTORY - PLEASE ANSWER TO THE BEST OF YOUR KNOWLEDGE. EVERY QUESTION MUST BE FILLED OUT. Last time your pet ate?

3 Time:_____ History of seizures? Yes No Allergic to any medications? If yes, please describe:_____ Yes No Seen by a Veterinarian in the past 14 days? If yes, please describe:_____ Yes No On any medication? Including heartworm and flea prevention If yes, please describe:_____ Yes No Last given_____ Any vomiting, coughing, or diarrhea? If yes, please reschedule surgery and have your pet evaluated by your regular veterinarian. Yes No MALES: Have both testicles descended into the scrotum?

4 If not, it is $50 extra per undescended testicle Yes No N/A FEMALES: Is your animal pregnant? The spay procedure removes the uterus, which will terminate any pregnancy. There will be an additional pregnancy charge added to the invoice. I agree to allow the veterinarian to sterilize my pregnant pet if the veterinarian determines that the pet is a viable surgery candidate. Yes No N/A Please initial for all patients Initial_____ Microchip Number (Staff Use) Please Check or Circle: Only Available with Surgery.

5 Items must be requested on this form at drop off or before surgery. Dog Vaccinations/Tests: О Rabies (1yr) (3yr w/Proof).. $10 Required unless providing paper proof of current vaccine О Distemper/Parvo (Puppy or Adult)..$15 О Heartworm Test (yearly after 6 mos of age)..$20 О Bordetella (Kennel Cough)..$15 Cat Vaccinations/Tests: О Rabies (1yr) (3yr w/Proof)..$10 Required unless providing paper proof of current vaccine О Distemper (Kitten or Annual).. $15 О Feline Leukemia/FIV $25 О Leukemia vaccine (must be tested).

6 $15 Dog and Cat see prices on Page 2 О HeartGard (K-9 Monthly heartworm prevention) О 6 months О 12 months О NexGard (K-9 Monthly Oral Flea/Tick) О Single О 6 months О 12 months О Bravecto (K-9 3 month Oral Flea/Tick) #_____ О Frontline Tritak (Monthly Flea/Tick Topical) K-9 or Cat О Single О 6 months О 12 months О Seresto (K-9 or Cat-8 month Flea/Tick collar) О Advantage Multi (Cat Monthly Parasite Topical) О Single О 6 months О 12 months Additional Tests or Items: О E-collar (clear plastic cone).

7 $10 O Microchip (24hr Pet watch)..$25 O Nail $10 О Fecal (Bring fresh, labeled Sample).. $10 О Pre-Operative Blood $50 This checks a complete blood count, liver and kidney functions. These tests help detect underlying issues that may cause your pet to be at a higher risk for complications that could occur during anesthesia. Available to all pets but STRONGLY recommended for over 7 years of age. PET HISTORY - PLEASE ANSWER TO THE BEST OF YOUR KNOWLEDGE. EVERY QUESTION MUST BE FILLED OUT.

8 Staff Use Only: Carrier + Pet =_____ Carrier Only Weight=_____ Take Home Pain Medication: Gabapentin twice daily for 3 days: 300mg 100mg 50 mg/ml _____ Fleas Earmites Ticks Cryptorchid Hernia Ear/skin infection Weight: 11401 International Dr Richmond VA 23236 p: (725) f: Surgery Fees : Pet surgery prices include Pre Surgical Exam Full surgical anesthesia and pain medication Take home oral pain medication Capstar if needed for fleas Female Spay Prices Dog 2-100 lbs $85 >100 lbs fee $50 Female Cat $50 Pregnancy Dog Pregnancy Cat $30 $20 Male Neuter Prices Dog 2-100 lbs $75 >100 lbs fee $50 Male Cat $40 Cryptorchid (per undescended testicle) $50 Preventive Medications- Can only request/pick up day of surgery.

9 No refills available, Maximum- 12 month supply per pet. Please see your full service vet for future needs. Heartgard (max 2 packages) Prevents Dog Heartworms: given monthly for life Pet should be heartworm tested yearly after 6 months of age. Size of Dog 6mos 1 yr 1-25 LBS $30 $60 26-50 LBS $38 $76 51-100 LBS $44 $88 Bravecto (max 4 packages) Dog Only Fleas/Tick Pill lasts 3 months > lbs (small/Red) $40 (Med/Grn) $40 (Lrg/Blue) $40 NexGard (max 12 doses/2 boxes) Monthly Oral Chew Flea/Tick Prevention Dog Single 6 mos All Sizes $20 $90 Frontline GOLD (max 2 packages) Flea/Ticks.

10 Liquid on neck once a month Dog 6 dose ( 22lbs) $82 Dog 6 dose (23-44lbs) $84 Dog 6 dose (45-88 lbs) $86 Dog 6 dose (89-132lbs $86 Cat all weights $77 Individual 1 month dose $15 Cat Advantage Multi (max 2 packages) Fleas/Earmites/Heartworms/some intestinal parasites: liquid on neck once a month 6 months $72 Individual 1 month dose $15 Seresto (max 2 packages) Flea and Tick Collar: lasts 8 months Dog or Cat $57 Please read the following: Authorization of anesthesia, surgery and vaccinations: By my signature below, I request and authorize The Richmond Animal League, Inc.)