I have read and agree to all of the following:

1. I certify that I am 18+ years old.

2. I am the owner or agent of the owner of the animal described above and I have the authority to execute this consent. I have fully disclosed all known pertinent medical history of the animal named above to the best of my ability. To my knowledge the animal is in good health and has had no food or treats since 12:00 midnight last night unless otherwise instructed by the Clinic staff.

3. I understand that my pet will be given a very limited examination prior to the administration of anesthesia and that the West Valley Humane Society recommends that a full physical exam and appropriate blood work be performed by my veterinarian prior to outpatient surgery.

4. I also understand that my pet should be current on all vaccines, dewormed, and free of fleas/ticks/ear mites. I acknowledge the fact that the healthier my pet is the lower the risk of developing complications associated with anesthesia, surgery, and outpatient hospitalization.

5. I understand that the attending veterinarian for various reasons may decline my pet for surgery.

6. I hereby consent to and authorize the following: the use of appropriate anesthetics, other necessary medications, and the performance of sterilization surgery, commonly known as spay or neuter surgery, tattoo as permanent proof of sterilization.

7. I understand that during the performance of the foregoing procedure or operation unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure or operation or different procedures or operations than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedures or operations as are necessary and desirable in the exercise of the veterinarian's professional judgment.

8. I acknowledge that no guarantee of results has been given or implied by West Valley Humane Society or its staff members.

9. I have received an estimate of the probable costs of the procedure or operation or have declined to receive such an estimate. I understand that I am fully responsible for all costs incurred.

10. I also acknowledge that complications may develop during surgery or post-surgically and that I assume responsibility for all post-operative care and veterinary expenses incurred as a result of such surgery. I understand that WVHS strongly advises that I purchase an e-collar for post-surgical recovery. I understand that should my pet chew or lick the incision I am responsible for surgical repair costs.

11. I understand that all cats must arrive in separate carriers and dogs must arrive with a well-fitted collar/harness and a leash. I also understand that my animal must not have eaten after midnight the day of surgery.

12. I agree to pick up my pet at the time specified and I understand that if I fail to do so, I will be liable for overnight boarding fees.

13. I agree to indemnify and hold harmless the West Valley Humane Society, the attending veterinarian, and any of the officers or employees of said entity from any and all claims, damages and causes of action that may arise from the procedures or operations to be rendered, and from other medical care arising there from.

14. I have been advised as to the nature of the procedure or operation and the risks involved, including death. I have read and understand the Risks and Complications Fact Sheet.

15. West Valley Humane Society will provide limited vet services directly related to the incision and/or surgical complications with limited diagnostic ability. I may be referred to my own vet for additional care at my own expense.

16. This service is to be used for privately owned pets and is not to be used for: the sale of pets, low cost services for another rescue, or any other organization unless given explicit permission by the shelter.

17. My signature on this form indicates that I have read, discussed as necessary, and understand the possible risks and complications that may arise.