Your Pet's Name

Your pet's color

Are you currently a client with Verzijlenberg Veterinary Hospital?

I am a new client, interested in switching permanently to VVVH

I am a new client, not interested in switching permanently to VVH

I am already a client with VVH

What is your first and last name? (Please include anyone else who may be picking up, or dropping off your pet at our hospital)

What is the phone number we can reach you at?

What is your home address?

Email

Phone

Where is your current veterinary clinic? (only if you are not a client of VVH)

What species is your pet?

Canine

Feline

What sex is your pet>

Male

Female

How old is your pet? If you know their exact birthdate, please provide that. Please note that pets under 6 months or above 2 years of age do not quaigy for the spay/neuter program.

What breed is your pet? Try to be as specific as possible.

What is the approximate weight of your pet?

Does your pet have any previous or chronic medical issues? Thsi includes heart issues, seizures, allergies etc.

Is your pet on any medications or flea and tick prevention?

When was your pet vaccinated last?

Has your pet ever had any reactions to medications or vaccines in the past?

Yes

No

Dropdown

Males: Do you know if both testicles have descended?

Yes

No

My dog is a female:)

Females: Has your pet gone into heat?

Yes

No

My dog is a male:)

Females: Has your girl ever had a litter of kittens or puppies? If so, when was the last litter?

This question is for cats only, Does your cat go outdoors?

Indoors only

Outdoors only

I'm a dog, so you bet I like being outside

I understand that pre-anesthetic bloodwork is recommended prior to any surgical procedure, but that it is not required or included as part of the low cost program. Pre-anesthetic bloodwork is $182.00 + HST additional.

Single choice

I would like pre-anesthetic bloodwork for my pet.

I decline pre-anesthetic bloodwork for my pet.

I understand that I am being offered a free microchip at the time of my pet's procedure. I understand tht VVH will not register it for me, but just implant it and send me home with the documentation to full it out with my personal in formation on my own time.

Single choice

I would like pre-anesthetic bloodwork for my pet.

I decline pre-anesthetic bloodwork for my pet.

In understand that due to the nature of a high volume spay and neuter program, my pet will not be receiving an IV catheter or IV fluids. If I wish to have an IV catheter or IV fluids, I understand that my pet will be schedule on a separate surgical date and will not qualify for the low cost/high volume program

Single choice

I accept

I understand that VVH offers vaccinations ranging in price between $35.00 to $65.00 +HST. If my animal has not been vaccinated, or is not up to date, I understnad that VVH is not responsible for any risks associated with uncaccinated animals.

Single choice

I accept

I understand that I will be emailed consent forms to the email I provided to review, sign and bring in on the surgery date or email back to VVH. U understand if I cannot print these at home, I will be required to fill them out the morning of surgery

Single choice

I accept

I understand tht full payment for spay/neuter is requires when the appointment is scheduled. I understand that if my pet has not been seen by VVH prior to the surgical date, my pet may fall into a different weight category than anticipated and I may owe more money at the time of surgery.

Single choice

I accept

I understand that any extras or add-ons will be paid for at the time of dicharge from the surgery (vaccinations etc.)

Single choice

I accept

I understand when the form is submitted, we'll be contacted to schedule surgery and take full payment over the phone.

We have a cancelation fee of $100.00 + HST for dogs and $50.00 + HST for cats (rebooking does not apply).

Single choice

I accept

I Accept

I understand that the veterinarian can decline surgery on my pet without any reason.

I understand that if my pet is deeemed overweight, there will be an additional fee. For cats this fee is $85.00 + tax, for dogs less than 10kg this fee is $150 + tax, and for dogs greater then 10kg this fee is $250 + tax. This is due to the additional time in the procedure, medications and anesthetic.

Inunderstand that if my pet is deemed to be aggressive, there will be an addiotnal fee of $150 + tax. If this is the case, , I may be called back to the clinic to be with my pet during the pre-surgical exam and wait diruing the procedure. I may have to muzzle/mask my pet. I understand that if I am unable to come back during this time

I understand that if my pet is found to be pregnant, there will be an additional fee, and the pregnancy will be terminated if discovered while in surgery. For cats, this fee is $150 + tax, for dogs less than 10kg, this fee is $200 + tax, and for dogs over 10kg, this fee is $300 + tax.

I understand that if my pet is found to have a pyometra (infecion of the uterus) there will be an additional fee. Far cats, this fee is $200 + tax, for dogs less than 10kg, this fee is $300 + tax, and for dogs over 10kg, this fee is $400 + tax. My pet my also need to be prescribed additional medications baed on the discretion of the veterinarian, which would be on top of the forementioned prices.

I understand that if my pet is found to be in heat during the pre-surgical exam, surgery will be canceled the day of the procedure and a charge of $50 + tax will be charged that day. I understand that my pet will be rebooked to the next appropriate date in the future. I understand that if my pet goes into heat before the surgical date, ths appointmenent needs to be rescheduled.

I understand that my pet is required to fast starting 12 hours before drop off on the surgery day. My pet will be required to have no food starting at this time. If my pet is fed a meal after this time, we can decline the surgery and book for the next available date.

I understand that drop off and intake time for the surgery will be scheduled between 8:00 and 9:00am.

Verzijlenberg Veterinary Hospital

705-384-0400

Puppy and Kitten Spay and Neuter Program

Pre-surgical Questionnaire

I Accept