TNR Surgical Consent SURGICAL CONSENT FORM / PRE-SURGICAL HEALTHY EXAM FORMPlanned 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* Name (Pet Owner/Trapper)* First Last Phone*Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Organization*Public TNRBKMAFOPAID #Pet's Name*Pet's Age*Breed*Color/markings*Weight (lbs)*Pet's Gender*FemaleMaleUnknownRAWC 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* EmailThis field is for validation purposes and should be left unchanged.