TNR Surgical ConsentSURGICAL CONSENT FORM / PRE-SURGICAL HEALTHY EXAM FORM Planned Procedure:TNR = (spay/neuter, rabies, fvrcp, ear mite treatment, ear tip)ALL TNR PACKAGES INCLUDE THE SPAY/NEUTER, A RABIES VACCINE, AN FVRCP VACCINE, AND AN EAR TIP. WE REQUIRE PROOF OF VACCINES IF YOU DO NOT WANT US TO INCLUDE THEM IN THE PROCEDURE.Today's Date* MM slash DD slash YYYY Name (Pet Owner/Trapper)* First Last Phone*Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Organization* Public TNR BKMAF OPA ID #Pet's Name*Pet's Age*Breed*Color/markings*Weight (lbs)*Pet's Gender* Female Male Unknown RAWC ID #List ALL pertinent, previous, or ongoing health concerns (please include drug or vaccine reactions in the past. Note any vomiting, diarrhea, coughing, sneezing, nasal discharge, in-appetence, fever or weight loss in last month):***If fleas or worms are present, flea medication or de-wormer WILL be administered at the cost of the owner/trapper**Each cat must be in their own separate hard crate or trap. Due to limited kennel space, all animals will be returned to their crate for recovery. This creates less stress for the pet being in a familiar environment. Once the pet is in the crate a technician will monitor vitals until they are alert enough to go home. In extreme feral cases we will not be able to handle the pet once they are awake from anesthesia. WE ARE NOT IN THE CLINIC OVERNIGHT, IF YOUR PET MUST STAY WITH US, WE WILL MONITOR BEFORE LEAVING IN THE EVENING AND AGAIN FIRST THING IN THE MORNING.Optional Services Requested at additional cost: Flea Prevention ($20) Deworming ($10) Ear Cleaning ($15) Microchip ($25) Any additional services?With my signature I authorize Rayford Animal Wellness Clinic to perform the procedure listed above. I understand that with any surgery there is the inherent risk of anesthesia and surgical complications which could include death. Rayford Animal Wellness Clinic will not be liable for any additional costs these complications may incur, and I do not hold Rayford Animal Wellness Clinic responsible for any unforeseen complications. I have read and understand these terms.Owner's Signature*Signature Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.