Pittsboro Animal Hospital

919-542-5750 (fax)

1065 East Street, Pittsboro, NC 27312

Low Cost Spay/ Neuter

Low Cost Spay/ Neuter Consent Form

Please fill out the entire form

Client Information

First Name: *
Last Name: *
Phone Number *
Phone Number 2

Pet Information

Pet Name: *
Pet Breed and Color: *
Pet Age: *
Pet Sex:

When did your last eat: *
Does your pet have any of the following health concerns?

  excessive drinkingexcessive urinationweaknesslimping
Other health concerns:

Pre-anesthetic blood work

It is highly recommended your pet have basic Pre-anesthetic blood panel performed before surgery. Please pick one: :


My dog is current on monthly heartworm prevention:

If your dog is not current on monthly heartworm prevention we recommend a heartworm test be performed. Dogs that are heartworm positive have an increased risk under anesthesia:

Additional Services

Please check any additional services you would like performed at a discounted rate

  Heartworm Test (dog only)
  FeLV/FIV test (cat only)
  Fecal Intestinal Parasite Test
  Distemper Vaccine (cat or dog)
  Rabies Vaccine (cat or dog)
  Leptospirosis Vaccine (dog only)
  Feline Leukemia Vaccine (cat only)
  Pain Medication (cat or dog)
  Microchip with Registration (cat or dog)

Consent Authorization

  I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the pet described above. I authorize the doctor and assistants to perform the procedures listed above, including administration of pain medication, sedative/ anesthetics, as well as any necessary and appropriate medical, rediological, surgical and nursing, diagnostics, and/or emergency care for my pet. I have been advised as to the nature of the procedure(s) and potential risks. I also understand that no guarantee of successful treatment can be made
  I have read and fully understand the reason for and the risks of the above procedure(s) and assume FULL financial responsibility for ALL charges and services incurred for my pet.
By typing my name here I am signing this form and acknowledge the two above check boxes have been read and fully understood: *
Date: *