Hicksville Vet Clinic uses qualified staffing 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 for humans who undergo surgery. Carefully read and understand the following before signing your name. I, acting as owner or agent of the pet named above, hereby request and authorize Hicksville Vet Clinic, through whomever veterinarians they may designate, to perform an operation for sexual sterilization of the animal named on the above portion of this form.
• I understand that the operation presents some hazards and that injury to or death of such an animal may conceivably result, for there is some risk in the procedure and the use of anesthetics and drugs in providing this service.
• 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 certify that my animal is in good health and has had no food since 9:00 p.m. the evening prior to surgery.
• I understand that Hicksville Vet Clinic has the right to refuse service to any animal to whom surgery is deemed a health risk.
• I understand that Hicksville Vet Clinic may not perform a complete physical examination before surgery is performed.
• I understand that my animal will not receive pre-operative blood work, unless prior arrangements were made at additional charge.
• I understand that some factors significantly increase surgical risk, including but not limited to, diseases such as Feline Immunodeficiency Virus, Feline Leukemia, and heartworms.
• I understand that if my animal is cryptorchidic (one or both testicles have not descended), my animal will stay overnight to receive the surgery it needs.
I understand that if I don’t retrieve my pet at the agreed upon time that Fort Defiance Humane Society will consider holding the pet for 3 days and then placing it up for adoption. Owners of pets left after the agreed time shall be charged a boarding fee of no less than $20 per day. I hereby release Fort Defiance Humane Society, Hicksville Vet Clinic, all veterinarians, assistants, volunteers, directors, and employees from any and all claims arising out of or connected with the performance of the procedure or any adverse reactions from sterilization. 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 hereby agrees to indemnify and hold Fort Defiance Humane Society and Hisksville Vet Clinic harmless from 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.
