Surgical Liability Waiver

Pet Owner's Name*

First Last

Physical Address.*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Alternate Phone Number

Date of Surgery*

Surgery being performed*

Spay (Females)

Neuter (Males)

Pet's Name:*

Pet Species*

Feline

Canine

Sex of Pet:*

Male

Female

Primary Breed:*

My pet is a*

Purebred

Mixed Breed

Primary Color:*

AVHS uses qualified staff and approved materials for all procedures performed. It is important for you to understand that the risk of injury or death is always present. Please carefully read the following statements, initialing each paragraph in agreement. If you disagree with or have questions about a statement, please consult with AVHS staff prior to initialing.

I, acting as the guardian of the animal above, hereby authorize Ark-Valley Humane Society veterinary services, through whomever veterinarian they may designate, to perform sterilization (spay or neuter) surgery on the animal named and described on this form. I own and have all rights regarding this pet.*

I understand that AVHS has the right to reschedule or revoke service to any animal whom surgery or preparation for surgery is deemed to be a health risk to either the animal itself, other animals under the care of AVHS, and/or the medical staff.*

If in the course of treatment a condition is discovered that requires medical attention or an additional procedure, such as hernia repair or the administration of IV fluids, the attending veterinarian may, in their absolute discretion, perform such procedure.*

I agree that I will be available by phone today. If a situation arises and I cannot be reached at the number provided on this form, I authorize the veterinarian to use their discretion and clinical judgement as to how to proceed. I understand that the AVHS staff may not leave a message, and that I must be available by phone during the day of the procedure.*

I understand that there are medical risks associated with the procedure including, but not limited to: infection, hemorrhage, allergic reaction, anesthetic drug reaction, anesthesia-induced cardiac compromise, and death. I understand that AVHS will perform a physical exam, but not perform a comprehensive cardiac exam and other diagnostic tests prior to the procedure. Pre-surgical bloodwork will only be performed if I specifically request it, as indicated on this form below. I understand there are increased risks due to the fact that AVHS will not perform extensive preoperative diagnostic evaluations.*

I understand that pre-surgical bloodwork is recommended to help identify hidden health issues that could increase anesthetic risk. Bloodwork evaluates organ function, red and white blood cells, and other indicators that may not be detected during a physical exam. Abnormal results may require changes to the anesthetic plan or postponement of surgery for your pet’s safety.*

Please select one:*

YES, I authorize pre-surgical bloodwork for an additional charge of $85.

NO, I decline pre-surgical bloodwork. I understand that declining this testing may increase anesthetic and surgical risk, including serious complications or death. I accept responsibility for this decision.

I understand that some factors, known or unknown, significantly increase surgical risk including but not limited to: pregnancy, heat cycles, and diseases such as FIV, Feline Leukemia, and heartworms. I have notified AVHS of any or all of these contributing factors if known.*

I understand that if this animal is pregnant, the pregnancy may be terminated at the time of surgery.*

To the best of my knowledge, this animal is in good health. I accept full responsibility for all preoperative and postoperative care of this animal. I will indemnify and hold harmless Ark-Valley Humane Society, the attending veterinarian, and any of the employees of said entity from any kind of liability arising out of, or connected with the performance of all procedures referred to above. I agree that I have not and will not claim any right of compensation from any of them, or file action by reason of such surgical procedure(s) or attempted surgical procedure(s) of such animal or any consequences related hereto.*

I agree that once this animal is released back into my care I will be financially responsible for any postoperative medical treatment relating to this procedure, beyond any medications provided to me by AVHS on the day of release, as well as continue to be financially responsible for any other unrelated medical problems of this animal.*

I certify that this animal has not bitten a person in the last ten days.*

I understand that if I do not retrieve this animal at the agreed upon time, AVHS will exercise its right to adopt the pet out after five days of no contact, authorized by Colorado Law. If I do not retrieve my pet at the agreed upon time, I will be charged a boarding fee of $15 per night.*

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I UNDERSTAND THAT THIS IS A RELEASE FROM LIABILITY AND A CONTRACT BETWEEN AVHS AND MYSELF. I SIGN IT OF FREE WILL.

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Surgical Liability Waiver