SURGERY
CONSENT

In order to carry out surgery on an animal, The Clinic require a completed Surgery Consent & Waiver form, click below to get started.

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DOES YOUR PET MEET SURGERY REQUIREMENTS?

My pet does not have a medical condition that prevents it from having surgery

My pet is over 4 months of age

My pet is under 7 years of age

My pet cat weighs over 3 pounds

My pet dog weighs over 4 pounds

Your pet must meet these basic requirements in order to be eligible for surgery

Surgery Consent Form

SPAY & NEUTER SURGERY CONSENT AND WAIVER

First name*

Last name*

Rescue/Shelter/Organization Name

Email*

Phone*

Address*

Who is the guardian of this pet?*

I am the sole guardian

A Rescue/Shelter is the guardian

Please select an option if you are eligible to receive discounts

I am an authorized Rescue/Shelter Partner

I am a paid member of the SPCA of Polk County

I am a serving member of the military or a veteran

I am over 65 years old

Please note: staff are required to validate discounts and may ask for identification or confirmation notices, please have this ready upon checkout

PET INFORMATION

Pet Name*

Species*

Dog

Cat

Sex*

Male

Female

Age*

Breed*

Primary & Secondary Color*

Would you like to include inserting a free microchip in your pet?*

Yes

No, the pet has a microchip, listed below

Your pet is eligible to receive a free microchip with registration, included in your pets surgery fee.

Microchip Number

Does your pet have any current medical conditions (including coughing, sneezing, vomiting or diarrhea) or taking medications?*

Yes

If "Yes" above, please describe

Please select if you would like to purchase an Elizabethan Collar for your pet following surgery*

Yes, an Elizabethan Collar (Plastic Cone)

Yes, an Inflatable Reusable Collar

Yes, a Body Suit

No, I already have one

No, I understand the risks for not using one

It is highly recommended that all animals wear an Elizabethan collar for their own safety, following surgery

Please select if you would like other wellness services carried out for the pet

DHPP Vaccine (6-in1) for Dogs

DHPP+Lep Vaccine (7-in1) for Dogs

Bordetella Vaccine for Dogs

FVRCP Vaccine for Cats

Rabies 1 Year Vaccine

Rabies 3 Year Vaccine (if applicable)

Heartworm Test

Fecal Float Test

Nail Trim

Ear Cleaning

Skin Scrape

Express Glands

Deworming

By selecting services, you understand that each carry a fee and are not included in the standard surgical service of your pet

Other Surgical Services

The pet may require additional surgical services at the time of surgery due to unforeseen circumstances or due to a lack of history, undiagnosed or undetected conditions. In the interests and well-being of the pet, the Veterinarian may perform such services, which may incur a fee.

These additional services, may include but not limited to:

Umbilical Hernia
Cryptorchid
Pyometra
In-Heat
Pregnant
Deciduous Tooth

Where we aim to contact clients prior to additional services being carried out, it may not always be possible due to the immediate need of the pet.

CONSENT & WAIVER TERMS

Pre-Operative Requirements

I acknowledge that I have followed all pre-operative requirements, in order for my animal to receive sterilization surgery with The Clinic*.

Vaccinations

I acknowledge that it is recommended that all animals admitted to The Clinic be vaccinated and that, in the event my animals is not fully vaccinated prior to surgery, I understand the associated risks, such as Parvovirus, kennel cough and, but not limited to respiratory infections post-surgery; and that I am responsible for treatment(s) at my own cost.

Bloodwork

I understand that The Clinic does not perform pre-surgical blood work and that my animal may have underlying medical conditions that place them at risk. I understand that blood work must be performed at a full service veterinary clinic.

Pre-Surgical Exam

I understand that my animal will receive a pre-surgical exam and that the veterinarian has the right to decline to perform any procedure for any animal for any reason.

Anesthesia & Medical Procedure

I understand that my animal will receive anesthesia and a medical procedure and that it presents some hazards, including but not limited to post operative infections, respiratory issues and/or death. I understand and accept these risks.

Tattoo

I understand that my animal will receive a small tattoo on their underside to show that they have been sterilized.

Pickup & Payment

I understand and agree that should I fail to collect my animal prior to closure on the date of surgery, that I will incur a boarding penalty of $30 per night.

I agree to pay fees for requested services at the time of service, including associated fees for additional services carried out, such as umbilical hernia repair, cryptorchid castration, in-heat, pregnancy or pyometra medical procedures and/or additional medications required.

Post Operative Care

I agree to follow all post-surgical care instructions, or any other instructions received by me or my representative from The Clinic.

I understand and agree that I will contact a full-service veterinary clinic, should my animal develop complications following this medical procedure and that I am responsible for associated fees incurred.

I understand that it is my responsibility to ensure all post-operative care instructions are received and carried out and to monitor my animal recovery and general health.

I understand that it is highly recommended that my animal wear an Elizabethan collar or body suit and that I understand the risks and accept responsibility for not obtaining or utilizing an Elizabethan collar or body suit.

General Release

I agree to waive any and all claims for damages against The Clinic*, its officers, agents, or employees and the SPCA of Polk County in the event of illness, injury or death of my animal arising from the hospitalization and/or surgical procedures.

CARDIOPULMONARY RESUSCITATION (CPR)

In the event of an emergency during surgery, it is standard practice to perform Cardiopulmonary Resuscitation (CPR) on an animal. Performing this action, may lead to fractures, bruising or other injuries, including but not limited to death. In order to proceed with surgery, please notify us of your intention should an emergency arise.

Please select an option for emergency needs of the pet*

Selecting "Do Not Resuscitate (DNR)", will mean that CPR will not be performed on the pet.

UPLOAD FILES

File upload

Please upload the pets Rabies certificate or other medical records (if applicable)

By signing, I, the owner/the authorized agent have the authority to execute this consent and waiver, and acknowledge that I have read, understood and agree to all the terms listed above, and confirm that all the information given on this form is correct to the best of my knowledge.

Signature*

Sign with a mouse, stylus or your finger, or upload a saved signature.

Select your appointment date*

This lets us match your form with your appointment, saving you time at check-in

*The Clinic is a DBA of the Society for the Prevention of Cruelty to Animals of Polk County, TX, INC.

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Feel free to donate to the SPCA of Polk County here to help support animal welfare and continue to provide affordable services in your community.

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