Low Cost Spay/Neuter Clinic
       "Help us make a humane difference in our community."
                epaaonline2009@gmail.com​

                Eastern PA Animal Alliance- Release Form
​​Fill out completely or surgery will not be able to be performed.  Must print on one page.

Date _____________ Human's Name __________________________________________________

Address ______________________________________City______________________Zip__________

Phone # where you can be reached today. ______________________________________________
Pick up is 1 hour after call.  Late fee $25


Pets
Check one Cat-Dog Name, age & color _______________________________________________

_________________________________________________________________________________​_
Male                   Female

​If you pay the feral/stray price the cat will receive an ear tip. These cats do not live inside your home.

​​Feral/Stray Cat(s) # ___________These are cats in traps that will be altered and returned to area trapped.
All will be ear-tipped for identification there is no exception. Feral/stray cats do not live in a house.

EPAA uses qualified staffing and approved materials for all procedures performed. It is important for you to understand that the
​risk of injury or death, although extremely low, is always present just as it is for humans who undergo surgery.
Carefully read and understand the following before signing your name.
I, acting as owner or agent of the pet named above, hereby request and authorize EPAA, through whomever veterinarian they may designate, to perform an operation for sexual sterilization of the animal named/described on the above portion of this form.
I understand that the operation presents some hazards and that injury to or death of such an animal may conceivably result, for there is some risk in the procedure and the use of anesthetics and drugs in providing this service.

I either certify that my animal has been vaccinated within one year prior to this date or waive my right to protect my animal by having it vaccinated, or request recommended vaccinations at the time of surgery. I understand that it takes up to two weeks for vaccinations to protect my animal. I understand the inherent risks of failing to maintain current vaccinations and waive all claims arising out of or connected with the performance of this operation due to such failure.

I certify that my animal is in good health and has had no food since 12:00 midnight the evening prior to surgery.
I understand that EPAA has the right to refuse service to any animal for any reason or to whom surgery is deemed a health risk. If the animal is found already to be altered there will be no refund.

I understand that EPAA may not perform a complete physical examination before surgery is performed.
I understand that some factors significantly increase surgical risk, including but not limited to, obesity, pregnancy, heat, and disease. I understand that if my animal is pregnant, the pregnancy will be terminated at surgery. Additional charges may incur.

 I understand that if my animal has an open umbilical hernia, it will be repaired at time of surgery at an additional charge of $15(cat), $15-$30(dog).

YOUR ANIMAL WILL RECEIVE A SMALL TATTOO ON HIS/HER UNDERSIDE TO SHOW THAT HE/SHE HAS BEEN STERILIZED.
I understand that the veterinarian performing this surgery is not available to deal with emergency post operative complications, but is available for post operative questions and review. An Elizabethan Collar is used to prevent licking at the surgical site and is required for all dogs and highly recommended for female pet cats. You may purchase an e-collar at the clinic. I agree to seek private veterinary care for complications that will occur from not using an e collar, improperly sized e collar, or if EPAA veterinarians are not available, which I will assume full financial responsibility.
I hereby release EPAA, all veterinarians, assistants, volunteers, officers, directors, and employees from any and all claims arising out of or connected with the performance of this procedure or any adverse reactions from vaccinations. I agree that I have not and will not claim any right of compensation from them, or any of them, or file action by reason of such sterilization or attempted sterilization of such animal or any consequences related thereto.


​Signature ______________________________________________________Date _______________________

Office use only
s/n ___35__60__125__175

e-c 10 15

vax R10 D15

worming/senergy $5 $12

nails 10

microchip 25

test 30 
misc. charges
___________________
____________________
Rescue/voucher

_____________________

sbtl ______________
Paid drop off ____________________

Owes at pickup_________

Final ______________