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Eastern Shore Animal Hospital uses qualified staff and approved materials for all procedures performed. It is important for you to understand that the risk of injury or death, although extremely low, is always present, just as it is in humans who undergo surgery. Carefully read, and ensure you understand the following before electronically signing your name at the bottom of this form.
- · I, acting as owner or agent of the above named pet, hereby request and authorize Eastern Shore Animal Hospital, through whomever veterinarians they may designate, to perform an operation for irreversible sexual sterilization of the above named animal.
· I understand that the operation I have elected to pursue may present some hazards, and that injury to, or death of, an animal may conceivably result. Therefore there is some risk in the procedure and in the anesthetic drugs used/ provided for the procedure.
· I either certify that my animal has been vaccinated within one year prior to this date, or waive my right to protect my animal by having it vaccinated, or request recommended vaccinations at the time of surgery. I understand that it takes up to two weeks for vaccinations to protect my 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 that if my pet develops an upper respiratory infection after surgery, I am responsible for treatment at my own cost.
· I certify that my animal is in good health and has had no food since 10:00 PM the evening prior to surgery.
· I understand that Eastern Shore Animal Hospital has the right to refuse service to any animal to whom surgery is deemed a health risk.
· I understand that Eastern Shore Animal Hospital may not perform a complete physical examination before surgery is performed. I also understand that my animal will not receive pre-operative blood work. I waive my right to have this service performed prior to surgery with a full-service veterinarian.
· I understand that some factors significantly increase surgical risk, including but not limited to; pregnancy, heat, and diseases such as Feline Immunodeficiency Virus (FIV), Feline Leukemia (FeLV), and heartworms.
· I understand that if my animal is pregnant, the pregnancy will be terminated.
· I understand that if my animal has an open umbilical hernia it will be repaired at the time of surgery at an additional charge.
· I understand that if I do not retrieve my pet at the agreed upon time, Eastern Shore Animal Hospital can exercise their right to turn the animal over the nearest Shelter/ Humane Society, or dispose of the animal as deemed just and proper, as allowed by the State of North Carolina under G.S 90-187.7(a). Owners of pets left after the agreed date shall be charged a boarding fee of no less than $20 per night.
· I hereby release Eastern Shore Animal Hospital, all veterinarians, technicians, assistants, volunteers, directors, and employees from any and all claims arising out of, or concerned with, the performance of this procedure or any adverse reactions from vaccinations administered. I agree that I have not and will not claim any right of compensation from them, or any of them, or file action by reason of such sterilization or attempted sterilization of such animal or any consequences related thereto. Owner/agent herby agrees to indemnify and hold Eastern Shore Animal Hospital harmless for any damages caused during the transportation of the animal, or for any damages caused by any unforeseeable events including; fire, vandalism, burglary, extreme weather, natural disasters, or acts of God. If selecting "proof of previous rabies vaccine" below, a rabies certificate or receipt of rabies vaccine administered by a licensed Veterinarian must be presented at the time of service.
Owner Electronic Signature
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- FVRCP, DAP and Rabies are included in the procedure.
***NOTE: YOUR ANIMAL WILL RECEIVE A SMALL TATTOO ON HIS/ HER UNDERSIDE AS PROOF OF STERILIZATION***