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100 Caja del Rio Road
Santa Fe, NM 87507

Main Phone: 505.983.4309
Adoption: 505.983.4309 ext. 1610

Phone Inquiries: 10 a.m. – 6 p.m. daily
Kennel Viewing Hours: 11 a.m. – 5:30 p.m.

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Surgical Consent Form

"*" indicates required fields

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Surgical Patient Information

Please, provide your contact information.

Your Name*

First Last

Your Address

Street Address Address Line 2 City State ZIP Code

Your Email Address*

Email Address Confirm Email Address

Your Phone*

About Your Pet

We would love to know more about your pet.

Your Pet's Name*

Species/Type of Animal*

Dog

Cat

Rabbit

Breed*

Gender*

Female

Male

Color*

Age (please, indicate months or years)*

Consent For Surgical Sterilization

We need your consent to process this request.

Consent

I understand and accept the terms of the consent.

I, acting as owner/agent of the pet named above, hereby consent and authorize the Santa Fe Animal Shelter & Humane Society doctors and staff to receive, prescribe for, treat and/or operate upon the animal described above. I am the owner or duly authorized agent of the animal mentioned above.

The hospital doctors and staff are to use all reasonable precautions against injury, escape or destruction of the animal, and perform all procedures in a professional manner in keeping with accepted standards of veterinary medicine. All aspects of the animal’s case have been discussed with me and I understand the contents of this paragraph. With this in mind, I hereby release the hospital doctors and staff from further liability in this matter.

I am to be informed of any changes in the proposed care and treatment of the animal, as well as any change in the condition of the animal, except that if I cannot be reached and an emergency situation exists. The hospital doctors and staff are to use sound medical judgment in the care of the animal. I am to be informed of the discharge date of the animal, and will be expected to pay all charges in full upon the dismissal of the animal. Should the animal be left in the hospital beyond the discharge date without prior arrangements, I understand that the abandonment procedures will be initiated as outlined by New Mexico State Law. I further understand that I will be fully responsible for all accrued charges until the animal is removed from the hospital or considered abandoned by New Mexico State Law.

I understand that some factors significantly increase surgical risk, including but not limited to age, pregnancy, heat, and diseases such as FIV, FELV and heartworm. It is always recommended to have bloodwork and x-rays prior to anesthesia, especially in pets older than 6 years old. As a low cost facility we do not offer diagnostics that are normally recommended. I am aware that this can increase surgical and anesthetic risk and will not hold Santa Fe Animal Shelter and Humane Society, its doctors or staff responsible for any complications resulting from surgery. I am aware that if my dog is found to be in-heat or pregnant during surgery I will be charged an additional $20.00. I am aware that if my pet is found to be pregnant during surgery I will be charged and additional $20.00. I understand that the pregnancy will be terminated at surgery. I understand that if I arrive for my pet after 4:00PM, I will be charged a non-negotiable $50.00 late fee.

Owner's Name*

First Last

Signature Consenting to Pet's Surgical Sterilization*

Use your mouse or finger to draw your signature above.

Date*

MM slash DD slash YYYY

Medical History

Please take a moment to answer the following questions regarding your pet's health and any relevant experiences,

How long have you owned this animal?*

Within the past two weeks, has your pet displayed any of the following?*

Sneezing

Coughing

Vomiting

Diarrhea

Discharge from eyes/nose

None

Within the past two weeks, are you aware of any change in your pet's _____?*

Level of activity

Appetite

Water consumption

Weight

Urination/Defecation

No changes

Within the past two weeks, has your pet had any other symptoms that seem out of the ordinary to you?*

Yes

If you answered yes above, please explain*

Has your pet ever had a seizure?*

Yes

Are you aware of your pet having a history of (please check all that apply)*

Health Problems (ex. Arthritis, Heart Problems, etc)

Illness (ex.Parvo, Giardia, etc)

Injury (ex. Hit by Car, attacked by another animal, etc.)

No known problems

Other

If you answered yes above, please explain*

Does your pet have any lumps, tumors, hair loss or other skin problems?*

Yes

If you answered yes above, please explain*

Has your pet had an adverse reaction to vaccinations, drugs or anesthesia?*

Yes

If you answered yes to an adverse reaction, please explain*

Please list any medication your pet has taken in the past month and why (including heartworm preventative and any supplements)*

When was your pet's last heat cycle?*

Within the past 6 months, has your pet given birth?*

Yes

Please, indicate when your pet gave birth*

MM slash DD slash YYYY

In the past 10 days, has your pet been treated for fleas, ticks, or mange?*

Yes

What product was used to treat fleas, ticks, or mange?*

When was your pet's last heartworm test?*

MM slash DD slash YYYY

Is there anything else about your pet that our medical staff should be aware of?

Would you like us to microchip your pet?*

Yes

The spay/neuter appointment includes a microchip at no additional cost. There is no fee to register the microchip - 100% free! It is recommended to microchip all cats and dogs, but it is not required.

Has your pet had vaccines before?*

Yes

If yes, please bring a copy of your pet's vaccine records with you to the appointment. You can also have your other veterinarian email a copy of your pet's last vaccination records to spayneuter@sfhumanesociety.org. If your pet's last vaccines were done here or at the Clare Eddy THAW Animal, we will have those on file.

Does your pet need a rabies vaccine at the time of their surgery?*

Yes

If your pet is due for vaccines, the spay/neuter appointment includes a rabies vaccine at no cost.

Does your dog need a DAPP vaccine at the time of their surgery?*

Yes

If your pet is a dog, the spay/neuter appointment includes a DAPP vaccine at no cost.

Does your dog need a DAPP vaccine at the time of their surgery?*

Yes

If your pet is a dog, the spay/neuter appointment includes a DAPP vaccine at no cost.

Does your pet need a FVRCP vaccine? This is discounted to $5 on the day of surgery*

Yes

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