Patient/Client Information - Richmond Animal …

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. 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.

2 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? 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.

3 Yes No MALES: Have both testicles descended into the scrotum? 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. Items must be requested on this form at drop off or before surgery. Dog Vaccinations/Tests: О Rabies (1yr) (3yr w/Proof).

4 $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)..$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).

5 $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. 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.

6 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. 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 : 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.)

7 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. d/b/a The Loving Spay + Neuter Clinic (the Clinic ) to spay/neuter my pet and give vaccinations as I have indicated above, which may involve the administration of anesthesia to my pet. I understand the risks and potential complications involved in my pet s surgery and/or vaccination, and that injury, illness, or death of my pet may occur. I hereby release and hold harmless the Clinic and its veterinarians, assistants, volunteers, directors, officers, and employees from any and all claims or liabilities related to or arising out of the Clinic s performance of the surgery and/or vaccination authorized herein, including without limitation, death, injury, illness, or other adverse reaction that my pet may have as a result of the surgery and/or vaccination I am aware that the Clinic recommends that pets be up-to-date on all preventative vaccinations before coming to the Clinic for sterilization.

8 I am aware that the Clinic is a high-volume spay/neuter facility and the only vaccination required for my pet to be spayed/neutered is a rabies vaccination. I assume all risks associated with owning and/or exposure associated with an unvaccinated pet. I agree to allow the Clinic to place a small permanent mark on the underside of my pet, near the sterilization incision, that will indicate the Animal has been sterilized. I understand and give my permission that all animals admitted to the Clinic may be photographed/videoed for use on social media and/or other advertising. I agree to be available at the phone numbers provided and understand that the Clinic staff will attempt to contact me at that number to discuss any concerns that may arise.

9 If, in the course of examination or surgery, the veterinarian discovers a medical condition that requires additional treatment and I cannot be reached, the veterinarian, in his/her sole discretion, may treat the condition or decline surgery. I agree to allow the treatment and will pay reasonable extra charges, if any. In the event of a complication that requires additional hospitalization, the pet will be transported to another facility for further treatment at my expense. I agree to pay all charges at the time the pet is discharged from the Clinic. I understand that the Clinic DOES NOT ACCEPT CHECKS. I agree to pay the exact amount in cash or will present a credit card or money order to cover the charges. The Clinic is not staffed 24-hours a day.

10 Pets are ready for discharge from the Clinic at 4:00pm (dogs) and 4:30pm (cats). Pets must be picked up at the end of the surgery day. I understand that if my pet is ready to release and I do not pick up my pet by 5pm on the day of surgery, I will be charged a fee of $40 and Animal Control will be called at 5:15pm. I understand and agree that as the owner or responsible agent for the pet described above, I assume financial responsibility for the services provided by the Clinic. By signing this form, I hereby authorize the Clinic and its employees or agents to accept/hospitalize/treat and perform sterilization surgery, and prescribe/administer the medications and tests I have authorized for the pet described above. I understand that the Clinic is a licensed spay/neuter clinic only and not a full service veterinary hospital.