August XX, 2020 Dog Spay / Neuter Clinic Registration Form Please complete the form completely, as missing information may result in a cancellation. Step 1 of 5 20% For Sat June 20, we will be at a private business: 1749 Magnolia Ave, Long Beach, CA 90815 (Entrance is FROM THE ALLEY ONLY-DO NOT ENTER THE BUILDING) and we will have a drive through dropoff. We will only be fixing cats, but we will have vaccines, etc for cats as well.DetailsFor Sat June 20, we will be at a private business: 1749 Magnolia Ave, Long Beach, CA 90815 (Entrance is FROM THE ALLEY ONLY-DO NOT ENTER THE BUILDING) and we will have a drive through dropoff. We will only be fixing cats, but we will have vaccines, etc for cats as well.Drop-Off Time*9:30 am10:00 am10:30 am11:00 am11:30 amPlease select your desired drop-off time from the options below.Dog Spay / Neuter*Low Income (under $40k)Mid Income ($40k-$60k)High Income (over $60k)Optional Add-Ons Select All DHPP Bordatella Influenza Rabies Vaccine Flea Medication Dewormer Nail Trim Microchip Enter coupon code if you have one Total $0.00 Anesthesia / Surgery / Treatment Consent FormSECTION Anesthesia / Surgery / Treatment Consent FormOwner Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Home Phone*Phone where you may be reached today*Dog's Name*Dog's Breed*Dog's Sex*MaleFemaleDog's Age*Years/MonthsDog's Weight*Dogs must be a minimum of 2.5lbs (ideally 5lbs), 3 months old, and a maximum of 55lbs and 34" butt to head.In-Patient QuestionnaireSECTIONIn-Patient QuestionnaireLast food given the patient (time)*Last water given*Date of last vaccine. If none, skip.DHPPMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920RabiesMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920BordatellaMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Last Fecal ExamMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of last Heartworm TestMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(Pets that are overdue for vaccines are required to be made current during time of hospitalization.) To lessen risk of surgery for your cat, the FELV/FIV Test is highly recommended for all cats not currently vaccinated for the feline leukemia virus.Does your pet show any of signs of illness?*Is your pet taking any medication?*To lessen risks of anesthesia/surgical procedures all dogs over the age of 6 months must be current on heartworm testing and/or preventative medication.List pet's past surgeries* Has your pet had any previous reactions to anesthesia?*YesNoList any behavioral concerns (biting, timidness, needing special handling, etc.)* List any belongings left with pet* The hospital will not be responsible for any lost items. Microchip Registration FormSECTIONMicrochip Registration FormOwner Name* First Last Email* Cell Phone*Home PhoneWork PhoneAlternate Contact Name* First Last Alternate Contact Email* Alternate Contact Phone*Pet*CatDogSex*MaleFemalePet Name*Age*Breed(s)*Color(s)*Distinguising Marks, etc***If requested by authorities, you authorize us to share this information AUTHORIZATION I verify I am the owner (or Authorized agent for the owner) of the above named pet and authorize the above procedures to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian. I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian's professional judgment. I accept responsibility for any result in additional charges. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).AUTHORIZATIONI verify I am the owner (or Authorized agent for the owner) of the above named pet and authorize the above procedures to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian. I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian's professional judgment. I accept responsibility for any result in additional charges. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).Signature of Owner or Agent*Date Date Format: MM slash DD slash YYYY Total $0.00 Credit Card Card Details Cardholder Name PhoneThis field is for validation purposes and should be left unchanged.