Great Value Spay Neuter

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OWNER INFORMATION PET INFORMATION
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Name Name
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Address Species Breed
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Contact phone number Sex Date of birth

I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent. I hereby consent and authorize Yolinda Animal Hospital, Inc. staff to perform the following procedures or operations:

NEUTER SPAY NEUTER AND DENTAL SPAY AND DENTAL
Canine (<21 lbs) $189 Checkbox20.jpg $229 Checkbox20.jpg $289 Checkbox20.jpg $329 Checkbox20.jpg
Canine (21-35 lbs) $204 Checkbox20.jpg $234 Checkbox20.jpg $304 Checkbox20.jpg $334 Checkbox20.jpg
Canine (36-50 lbs) $224 Checkbox20.jpg $256 Checkbox20.jpg $324 Checkbox20.jpg $356 Checkbox20.jpg
Canine (51-75 lbs) $244 Checkbox20.jpg $304 Checkbox20.jpg $344 Checkbox20.jpg $404 Checkbox20.jpg
Canine (>75 lbs) $274 Checkbox20.jpg $344 Checkbox20.jpg $374 Checkbox20.jpg $444 Checkbox20.jpg
Feline $110 Checkbox20.jpg $179 Checkbox20.jpg $210 Checkbox20.jpg $279 Checkbox20.jpg
Spay/neuter prices include pre-surgical exam; anesthesia; monitoring; IV catheter and fluids (except for feline neuters); antibiotic injection, pain medicine to go home, and E-collar. Spay/neuter and dental prices include all of the above plus the dental BUT ADDITIONAL CHARGES FOR EXTRACTIONS, ANTIBIOTICS MAY APPLY. Please indicate here if you would you like to be called (at the phone number above) before we extract any teeth.Checkbox20.jpg
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I additionally consent to the assessment of the following charges if deemed appropriate by the veterinarian performing the surgery:
Cryptorchid neuter (when a testicle has not fully descended)
  • Inguinal - $50-$100
  • Abdominal - $100
In heat / obese / (pseudo)-pregnant / lactating / abnormal
  • Canine - $35 - $100 (by weight / complexity)
  • Feline - $25 - $50 (by weight / complexity)
Hernia repair
  • Canine and feline - $70 - $150 (by size / complexity)
It is generally impossible to know whether or not these charges will be applicable until after the surgical procedure has commenced.
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I would like the following optional extras:
Nail trim - $14 Checkbox20.jpg Ear cleaning......................................... Checkbox20.jpg Fel ($30) Checkbox20.jpg K9 ($39)
Anal gland expression - $22..................................................... Checkbox20.jpg DHPP vaccine...................................... Checkbox20.jpg 1 yr ($19) Checkbox20.jpg 3 yr ($36)
Microchip - $42 (Normally $55 – save $13 today only!)........ Checkbox20.jpg FVRCP vaccine..................................... Checkbox20.jpg 1 yr ($19) Checkbox20.jpg 3 yr ($36)
Extraction of baby teeth - $20 (per tooth)............................... Checkbox20.jpg FeLV vaccine....................................... Checkbox20.jpg 1 yr ($20) Checkbox20.jpg 2 yr ($40)
Rabies vaccine - $21.............................................................. Checkbox20.jpg Bordetella...................................................................................... Checkbox20.jpg 1 yr ($19)
Corona vaccine............................................................................. Checkbox20.jpg 1 yr ($19)
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We strongly recommend that pre-anesthetic blood work be done before the surgery. Such blood work allows us to ascertain kidney and liver function, the organs primarily responsible for processing the anesthetic drugs. It is absolutely vital that we know whether or not these organs are somehow compromised - if they are your pet is at an increased risk of death while under anesthesia.
I would like pre-anesthetic blood work to be done on my pet at an additional cost of $90 (mandatory if pet’s 4 years or older).. …….................... Checkbox20.jpg
I decline pre-anesthetic blood work. I understand and accept the anesthetic risks. …..…..…..…..…..…..…..…..…..…..…..…..…..…..…..…..……...... Checkbox20.jpg
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PLEASE READ THE FOLLOWING STATEMENTS AND INDICATE YOUR UNDERSTAND AND ACCEPTANCE BY INITIALLING TO THE RIGHT
I understand that a Capstar pill will be given to all pets who are found to have fleas, at an additional cost of $8-$10.
I understand that for payment we accept cash, Visa, MasterCard, American Express and Discover, but NOT checks.
I understand that although we will gladly address any concerns you may have about your pet’s health unrelated to the surgery, additional fees will apply.
I understand the nature of these procedures, their implications for my pet, and that there are certain risks and complications associated with any surgical procedure. I authorize the use of appropriate anesthesia and pain relief medication as needed before, during, or after the procedure, and understand there are risks associated with these, too. I further understand that, during the course of these procedures, unforeseen conditions may arise that necessitate additional procedures. I hereby consent and authorize the performance of such procedures as deemed necessary by the veterinarian. I understand that hospital support personnel will be used as deemed necessary by the veterinarian.
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Signature (must be over 18) Please print Date


Pet Medical History

If your pet is NEW to Yolinda Animal Hospital, please take the time to answer the following questions as completely and as accurately as you can.

When was your pet last vaccinated?
Dogs Cats
Rabies
DHPP
Bordetella
Corona
Rattlesnake
__ /__ / ____
__ /__ / ____
__ /__ / ____
__ /__ / ____
__ /__ / ____
Rabies
FVRCP
FeLV

__ /__ / ____
__ /__ / ____
__ /__ / ____


Is your pet current on a rabies vaccine?
Checkbox20.jpg no
Checkbox20.jpg yes

Does your pet have a history of any illness?
Checkbox20.jpg no
Checkbox20.jpg yes – please explain……………………………………………………………………………………………………………………………………………………

Does your pet have a history of seizures?
Checkbox20.jpg no
Checkbox20.jpg yes – please explain……………………………………………………………………………………………………………………………………………………

Is your pet currently on any medications including supplements?
Checkbox20.jpg no
Checkbox20.jpg yes – please specify……………………………………………………………………………………………………………………………………………………

Does your pet suffer from any of the following health problems?
- Heart condition
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Checkbox20.jpg yes – please explain………………………………………………………………………………………………………………………………………………
- Epilepsy / seizures
Checkbox20.jpg no
Checkbox20.jpg yes – please explain………………………………………………………………………………………………………………………………………………
- Thyroid disorder
Checkbox20.jpg no
Checkbox20.jpg yes – please explain………………………………………………………………………………………………………………………………………………
- Arthritis
Checkbox20.jpg no
Checkbox20.jpg yes – please explain………………………………………………………………………………………………………………………………………………
- Vaccine allergy
Checkbox20.jpg no
Checkbox20.jpg yes – please explain………………………………………………………………………………………………………………………………………………
- Penicillin allergy
Checkbox20.jpg no
Checkbox20.jpg yes – please explain………………………………………………………………………………………………………………………………………………

Has your pet had surgery before?
Checkbox20.jpg no
Checkbox20.jpg yes – please explain……………………………………………………………………………………………………………………………………………………

If you have already taken your pet to a veterinarian, please provide their name and telephone number here so we may obtain medical records:


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Clinic name Contact telephone number


Thank you!