SN Surgery Consent Form

To finalize your spay/neuter appointment, please complete the health/consent questions below & submit.

"*" indicates required fields

General Information

Your Email Address:*

Enter Email Confirm Email

Pet Owner Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have a mobile phone?*

Yes

No, I only have a landline

Phone #:*

Mobile Phone #:*

AWARE of NH currently fixes only male & female cats & male rabbits. How many pets do you need spayed/neutered?*

NOTE: If you have more than 4 cats/rabbits, add a note under "Additional Notes" at the end of the form. If you need information about programs for dogs, please contact us at spayneuter@awarenh.org.

Tell Us About Pet #1

Pet #1 is a:*

Name of pet #1:*

Approx. birthday or age of pet #1:*

How long have you had pet #1?*

Please describe cat #1:*

Color of pet #1?*

Is cat #1 spraying or marking?*

What breed is cat #1?*

Cat #1 breed & coat length*

Is female cat #1 currently pregnant or nursing?*

Has female cat #1 had kittens?*

If "Yes," how many litters has female cat #1 had?**

How long ago did cat #1 have her last litter?*

I got pet #1 from:*

Pet #1-Provide Details for "Other," Shelter, or Transport Service:*

Any other cats in the home with pet #1 that are NOT fixed?*

Pet #1: For cats NOT fixed, please specify males or females and ages in the home, including cats that don’t belong to you (e.g., roommate's cat)*

NOTE: Please do NOT include the other cats you are including in this application.

Would you like Pet #1 to be microchipped for an extra fee?*

Yes

Unsure

Secondary Contact for Pet #1 Microchip*

First Last

Pet #1's Secondary Contact's Phone #:*

PET #1 HEALTH HISTORY

Please complete this additional information.

DOES PET #1 HAVE ANY HEALTH ISSUES?*

Yes

Please Explain Pet #1's Health Issues:*

HAS PET #1 RECEIVED A FLEA TREATMENT IN THE 30 DAYS PRIOR TO THE CLINIC?*

Yes

When was pet #1's flea treatment and what kind/brand?*

HAS PET #1 RECEIVED ANY EAR MITE TREATMENTS IN THE 30 DAYS PRIOR TO THE CLINIC?*

Yes

When was pet #1's last ear mite treatment*

HAS PET #1 BEEN VACCINATED FOR DISTEMPER/FVRCP?*

Yes

When was Pet #1's Distemper vaccination AND when does it expire. Approximations are ok.*

HAS PET #1 BEEN VACCINATED FOR RABIES?*

Yes

When was Pet #1's Rabies vaccination AND when does it expire. Approximations are ok.*

HAS PET #1 BITTEN ANYONE IN THE LAST 10 DAYS?*

Yes

Tell Us About Pet #2

Pet #2 is a:*

Name of pet #2:*

Approx. birthday or age of pet #2:*

How long have you had pet #2?*

Please describe cat #2:*

Is your cat #2 spraying or marking?*

Color of pet #2?*

What breed is cat #2?*

Cat #2's breed & coat length*

Is female cat #2 currently pregnant or nursing?*

Has female cat #2 had kittens?*

If "Yes," how many litters has female cat #2 had?**

How long ago did cat #2 have her last litter?*

I got pet #2 from:*

Pet #2-Provide Details for "Other," Shelter, or Transport Service:*

Any other cats in the home with cat #2 that are NOT fixed?*

Cat #2: For cats NOT fixed, please specify males or females and ages in the home, including cats that don’t belong to you (e.g., roommate's cat)*

NOTE: Please do NOT include the other cats you are including in this application.

Would you like Pet #2 to be microchipped for an extra fee?*

Yes

Unsure

Secondary Contact for Pet #2 Microchip*

First Last

Pet #2's Secondary Contact's Phone #:*

PET #2 HEALTH HISTORY

Please complete this additional information.

DOES PET #2 HAVE ANY HEALTH ISSUES?*

Yes

Please Explain Pet #2's Health Issues:*

HAS PET #2 RECEIVED A FLEA TREATMENT IN THE 30 DAYS PRIOR TO THE CLINIC?*

Yes

When was pet #2's flea treatment and what kind/brand?*

HAS PET #2 RECEIVED ANY EAR MITE TREATMENTS IN THE 30 DAYS PRIOR TO THE CLINIC?*

Yes

When was pet #2's last ear mite treatment*

HAS PET #2 BEEN VACCINATED FOR DISTEMPER/FVRCP?*

Yes

When was Pet #2's Distemper vaccination AND when does it expire. Approximations are ok.*

HAS PET #2 BEEN VACCINATED FOR RABIES?*

Yes

When was Pet #2's Rabies vaccination AND when does it expire. Approximations are ok.*

HAS PET #2 BITTEN ANYONE IN THE LAST 10 DAYS?*

Yes

Tell Us About Pet #3

Pet #3 is a:*

Name of pet #3:*

Approx. birthday or age of pet #3:*

How long have you had pet #3?*

Please describe cat #3:*

Is cat #3 spraying or marking?*

Color of pet #3?*

What breed is cat #3?*

Cat #3 breed & coat length*

Is female cat #3 currently pregnant or nursing?*

Has female cat #3 had kittens?*

If "Yes," how many litters has female cat #3 had?*

How long ago did cat #3 have her last litter?*

I got pet #3 from:*

Pet #3-Provide Details for "Other," Shelter, or Transport Service:*

Any other cats in the home that are NOT fixed with cat #3?*

Cat #3: For cats NOT fixed, please specify males or females and ages in the home, including cats that don’t belong to you (e.g., roommate's cat)*

NOTE: Please do NOT include the other cats you are including in this application.

Would you like Pet #3 to be microchipped for an extra fee?*

Yes

Unsure

Secondary Contact for Pet #3 Microchip*

First Last

Pet #3's Secondary Contact's Phone #:*

PET #3 HEALTH HISTORY

Please complete this additional information.

DOES PET #3 HAVE ANY HEALTH ISSUES?*

Yes

Please Explain Pet #3's Health Issues:*

HAS PET #3 RECEIVED A FLEA TREATMENT IN THE 30 DAYS PRIOR TO THE CLINIC?*

Yes

When was pet #3's flea treatment and what kind/brand?*

HAS PET #3 RECEIVED ANY EAR MITE TREATMENTS IN THE 30 DAYS PRIOR TO THE CLINIC?*

Yes

When was pet #3's last ear mite treatment*

HAS PET #3 BEEN VACCINATED FOR DISTEMPER/FVRCP?*

Yes

When was Pet #3's Distemper vaccination AND when does it expire. Approximations are ok.*

HAS PET #3 BEEN VACCINATED FOR RABIES?*

Yes

When was Pet #3's Rabies vaccination AND when does it expire. Approximations are ok.*

HAS PET #3 BITTEN ANYONE IN THE LAST 10 DAYS?*

Yes

Tell Us About Pet #4

Pet #4 is a:*

Name of pet #4:*

Approx. birthday or age of pet #4:

How long have you had pet #4?*

Please describe cat #4:*

Is cat #4 spraying or marking?*

Color of pet #4?*

What breed is cat #4?*

Cat #4 breed & coat length*

Is female cat #4 currently pregnant or nursing?*

Has female cat #4 had kittens?*

If "Yes," how many litters has female cat #4 had?*

How long ago did cat #4 have her last litter?*

I got pet #4 from:*

Pet #4-Provide Details for "Other," Shelter, or Transport Service:*

Any other cats in the home that are NOT fixed with cat #4?*

Cat #4: For cats NOT fixed, please specify males or females and ages in the home, including cats that don’t belong to you (e.g., roommate's cat)*

NOTE: Please do NOT include the other cats you are including in this application.

Would you like Pet #4 to be microchipped for an extra fee?*

Yes

Unsure

Secondary Contact for Pet #4 Microchip*

First Last

Pet #4's Secondary Contact's Phone #:*

PET #4 HEALTH HISTORY

Please complete this additional information.

DOES PET #4 HAVE ANY HEALTH ISSUES?*

Yes

Please Explain Pet #4's Health Issues:*

HAS PET #4 RECEIVED A FLEA TREATMENT IN THE 30 DAYS PRIOR TO THE CLINIC?*

Yes

When was pet #4's flea treatment and what kind/brand?*

HAS PET #4 RECEIVED ANY EAR MITE TREATMENTS IN THE 30 DAYS PRIOR TO THE CLINIC?*

Yes

When was pet #4's last ear mite treatment*

HAS PET #4 BEEN VACCINATED FOR DISTEMPER/FVRCP?*

Yes

When was Pet #4's Distemper vaccination AND when does it expire. Approximations are ok.*

HAS PET #4 BEEN VACCINATED FOR RABIES?*

Yes

When was Pet #4's Rabies vaccination AND when does it expire. Approximations are ok.*

HAS PET #4 BITTEN ANYONE IN THE LAST 10 DAYS?*

Yes

Consent for Surgery

Please complete this additional information.

Signature*

Today's Date*

Additional Notes?

Anything else we need to know?

This field is for validation purposes and should be left unchanged.

Helping People Help Pets.

To finalize your spay/neuter appointment, please complete the health/consent questions below & submit.

General Information

Tell Us About Pet #1

PET #1 HEALTH HISTORY

Tell Us About Pet #2

PET #2 HEALTH HISTORY

Tell Us About Pet #3

PET #3 HEALTH HISTORY

Tell Us About Pet #4

PET #4 HEALTH HISTORY

Consent for Surgery

Additional Notes?

Dec. 5th, 5pm - 8pm

OPEN HOUSE