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Name of Pet:____________________________ Date:_____________________
Species:____________ Age:___________ Sex:______________

I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give Dr. Barbara J Wynne, her agents, servants, and/or representatives full and complete authority to perform the surgical procedure described below. I do herby release the said doctor, her agents, servants, or representatives from any and all liability arising from said surgery on said animal. I understand that I will be charged for 1 package of topical flea medication and a dose will be applied if evidence of fleas is found on my pet.

Please Check the Appropriate Procedure:
We perform the following services for no charge when your pet is under anesthesia, unless you specify otherwise.
Toe Nail Trim - No Charge
Ear Cleaning - No Charge

We highly recommend the following services to be done. Call for additional costs.
Canine Vaccinations: DH2LPPC____Rabies____Bordatella____Lyme____
Feline Vaccinations: FVRCP____ FELV____ Rabies____
Feline FIV/FELV Test: Yes____ No____
spread by direct contact with infected cat
recommended for all newly aquired kittens and all outdoor cats
Junior Wellness Bloodwork: Yes____ No____
10% of young, active pets have been found to have illnesses or disease on routine bloodwork.
Includes Free heart worm test.
Senior Wellness Bloodwork: (8 years & older) Yes____ No____
40% of strong, active, pets have been diagnosed with progressive and potentially fatal illnesses.
Early detection has improved the outcome at significantly decreased cost.
Avid Microchip: Yes____ No____
allows the safe return of your lost or stolen pet
Dental Prophy With Surgical Procedure: Yes____ No____
Tartar and gingivitis lead to tooth decay and painful teeth
Infected teeth are the leading cause of heart and liver disease
IV Catheter: Yes____ No____
Allows us to give fluids to keep blood pressure up during surgery
Allows for faster deliver of emergency medications if problems occur with your pet
Requires the clipping of hair on the front leg. On rare occasions hair may not grow back or become discolored

I will be paying today with Cash____ Check____ Credit Card____


Number where I can be reached between 9am and 5pm today: ________________________________________________