Spay/Neuter Appointment Request Form

Owner Name *

First

Last

Owner Email Address *

Owner Phone Number *

This is the best number to reach you all day long on the day of your appointment

Alternate Phone Number

Owner Street Address *

Zip Code *

Have you attempted to access veterinary service through low cost clinics such as Emancipet, Houston Humane, KAAWS, Texas Litter Control, and SNAP *

Yes
No

How many pets would you like to schedule for spay/neuter appointments? *

1
2
3
4

Do you own the pet(s) for which you are seeking this service? *

Own
Intend to rehome
I am fostering for an organization

For which organization are you fostering? *

Why are you rehoming the pet(s)? *

Laurel's House may be able to offer additional resources to help you keep your pet

Pet Name *

Pet Type *

Select from dropdown menu

Pet Sex *

Select from dropdown menu

Pet Age *

Pet Breed *

Pet Coat Color *

Pet Weight *

Estimate is fine

How long have you owned this pet? *

Has your pet ever been aggressive toward people? *

An answer of 'Yes' does not disqualify pets from receiving service. We need to know for our safety and the safety of your pet. Please be honest.

Pet 2 Name *

Pet 2 Type *

Select from dropdown menu

Pet 2 Sex *

Select from dropdown menu

Pet 2 Age *

Pet 2 Breed *

Pet 2 Coat Color *

Pet 2 Weight *

Estimate is fine

How long have you owned Pet 2? *

Has Pet 2 ever been aggressive toward people? *

An answer of 'Yes' does not disqualify pets from receiving service. We need to know for our safety and the safety of your pet. Please be honest.

Pet 3 Name *

Pet 3 Type *

Select from dropdown menu

Pet 3 Sex *

Select from dropdown menu

Pet 3 Age *

Pet 3 Breed *

Pet 3 Coat Color *

Pet 3 Weight *

Estimate is fine

How long have you owned Pet 3? *

Has Pet 3 ever been aggressive toward people? *

An answer of 'Yes' does not disqualify pets from receiving service. We need to know for our safety and the safety of your pet. Please be honest.

Pet 4 Name *

Pet 4 Type *

Select from dropdown menu

Pet 4 Sex *

Select from dropdown menu

Pet 4 Age *

Pet 4 Breed *

Pet 4 Coat Color *

Pet 4 Weight *

Estimate is fine

How long have you owned Pet 4? *

Has Pet 4 ever been aggressive toward people? *

An answer of 'Yes' does not disqualify pets from receiving service. We need to know for our safety and the safety of your pet. Please be honest.

Do any of the pets for which you are seeking care have a history of illness or injury? *

Have any of the pets for which you are seeking care ever had an allergic reaction to any medicine or vaccine *

How did you hear about our no-cost spay/neuter service *

OWNER REQUIREMENT: I understand that all cats must arrive in carriers small enough to fit in an airplane overhead bin *

I agree

OWNER REQUIREMENT: I understand that check-in time on surgery day is 7 am. I will call Laurel's House if I am unable to arrive on appointment day by 8 am *

I agree

OWNER REQUIREMENT: I will be available at the phone number provided all day on the agreed upon surgery date *

I agree

OWNER REQUIREMENT: I will pick up my pet immediately after I am notified they are ready. I understand this could be any time between 10 am and 3 pm *

I agree

Due to space constraints, we are not able to keep your pet in the clinic after the veterinarian clears them to go home. Owners must immediately travel to the clinic for pickup when called.

OWNER REQUIREMENT: I will wear a mask when speaking with Laurel's House staff and volunteers *

I agree

I understand that if I fail to comply with the owner requirements above I will not be able to access Laurel's House services *

I agree

PROCEDURES: I understand that my pet will receive all core vaccinations (FVRCP and rabies if my pet is a cat; DA2PP and rabies if my pet is a dog). I understand that my pet will receive pain medications, undergo anesthesia, and receive surgery to remove their reproductive tract (spay/neuter). I understand that my pet will no longer be able to have puppies/kittens after surgery today. *

I agree

RISK OF ANESTHESIA: I understand that anesthesia and surgery carry inherent risks of complications including adverse reactions and death. I understand that my pet will receive a thorough physical exam by a veterinarian prior to surgery. I understand that some illnesses or conditions such as pregnancy, being in heat, heartworm disease, or feline viral diseases make surgery riskier and oftentimes cannot be detected on physical exam. I understand that bloodwork performed prior to surgery can help reduce the risks associated with anesthesia. I understand that bloodwork will not be performed on my pet prior to surgery today. I understand that if I wish to minimize the risks of anesthesia by having bloodwork performed, I will need to have all pre-surgical diagnostics and surgery performed at a full-service veterinary clinic. I understand that pre-surgical bloodwork is highly recommended for geriatric pets. *

I agree

PREGNANCY/RETAINED TESTICLES/UMBILICAL HERNIAS: I understand that if my female pet is pregnant, the pregnancy will be terminated at the time of surgery. I understand that if my male pet has a retained testicle, the abdomen will be explored and the retained testicle removed, resulting in multiple incisions. I understand that if my pet has an umbilical hernia (a defect in the body wall near the “belly button”) that this defect will be corrected at the time of surgery resulting in multiple incisions or one longer than normal incision. *

I agree

TATTOO: I understand that my pet will receive a permanent green line tattoo to indicate that they have been spayed/neutered. *

I agree

ADDITIONAL MEDICATIONS: I understand that if a veterinarian deems it necessary to administer antibiotics for a skin infection, parasite treatments for a heavy flea burden or intestinal worms, or medications for nausea after surgery, that these medications will be given to my pet at the veterinarian’s discretion. *

I agree

PAIN MEDICATIONS: I understand that my pet will receive non-steroidal anti-inflammatory pain medications that can be detrimental if my pet has underlying liver, kidney, or gastrointestinal disease. I understand that having bloodwork performed at a full-service veterinary clinic would minimize these risks. *

I agree

AFTERCARE: I understand that I will receive discharge instructions detailing how to care for my pet after surgery. I understand that failure to read and follow these instructions will increase the likelihood of complications developing after surgery. If my pet experiences complications or illness after surgery that require veterinary care, I understand that I am financially responsible to pay for that care. *

I agree

FASTING: I affirm that my pet has been fasted overnight. I understand that if my pet has not been fasted, this greatly increases the risk of anesthetic complications up to and including death. *

I agree

RIGHT TO REFUSE SERVICE: I understand that Laurel’s House has the right to refuse to perform vaccinations and/or surgery on my pet if it is deemed unsafe to do so due to the health or behavior of my pet. *

I agree

IMAGE RELEASE: Laurel’s House may use my name, and pictures, photographs, or video and/or sound recordings of me and/or my pet on television, on radio, on the internet, in emails, and in stores, news articles, advertisements, or other written or digital materials. I agree that such uses may include education, advocacy, and fundraising. I consent to and authorize, in advance, such use and agree that Laurel’s House does not have to notify me of such use or provide me with other considerations for such use. I waive any rights or privacy and/or publicity I may have in connection with these uses.

I agree
I do not agree

PERMISSION AND RELEASE: I hereby grant permission for my pet to undergo anesthesia, receive all core vaccinations, and undergo spay/neuter/umbilical hernia repair surgery. I hereby release Laurel’s House, all veterinarians, assistants, and volunteers from any and all claims arising out of or connected with the performance of these procedures or any adverse reactions from vaccinations or other medication. 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. I hereby agree to indemnify and hold Laurel’s House and other involved parties harmless for any damages caused during handling and treatment of the animal. I authorize release of veterinary medical records produced by Laurel’s House to any veterinarian that requests the records *

I agree

INFORMED CONSENT: I affirm that all questions about the risks posed to my pet have been answered to my satisfaction. *

I agree

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