Surgery Intake Form

Catsnip Spay/Neuter Services of GA
SURGERY INTAKE FORM
OWNER’S NAME Cell Phone
Emergency Name (in case of complications) Phone
Street Address
City, State, ZIP
Contact Email
Cat’s Name Age Mix or Breed
(Circle) Hair Length Short Med Long (Circle) Male Female Color
Pickup person (if different from owner)
Does your cat have any medical conditions (coughing, sneezing, vomiting, diarrhea, etc.)
If yes, please describe
Is your animal taking any medications such as insulin, thyroid or steroids?
If yes please describe
• CatSnip Spay/Neuter Services of GA (“CatSnip”) uses qualified staff & 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. 
• I, being lawfully authorized to make decisions on behalf of the animal named/described above (the “Cat”), hereby request and 
authorize CatSnip, including its affiliates & each of their employees, volunteers, veterinarians &/or other agents (collectively, 
“CatSnip Parties”), to receive, prescribe for, treat and/or administer vaccinations &/or perform an operation for sexual 
sterilization of the Cat and any related surgical treatments that CatSnip deems necessary for the health and safety of the Cat.
• I understand that the operation I have chosen presents some hazards & that injury to, post-operative infection in, or death of the 
Cat may result, for there is some inherent risk in the procedure & in the use of anesthetics & drugs provided for the procedure, as 
well as in any vaccines used. I understand that general anesthesia will be administered to the Cat for surgery. I understand and 
accept these risks.
• I understand that CatSnip and/or any of the CatSnip Parties has the right to refuse any service &/or procedure to any animal for 
any reason, including, but not limited to, situations where surgery is deemed a health risk. Such refusal is at the sole discretion of 
the attending veterinarian. ALL CATS MUST BE IN APPROVED CARRIERS or Cat will be put in a $7 cardboard carrier.
• I understand that a pre-surgery exam will be performed on the Cat when possible, but that there are times, in the attending 
veterinarian’s sole discretion, when such an exam may only be performed after the Cat has already been sedated or anesthetized. 
I understand that the Cat will not receive pre-operative bloodwork at CatSnip. If I choose for the Cat to have such bloodwork, I 
understand tht it must be performed at a full-service veterinary clinic before being presented for the operation at CatSnip. 
• I understand that some factors significantly increase surgical risk, including, but not limited to, pregnancy, heat, & diseases such 
as feline immunodeficiency virus (“FIV”), feline leukemia virus {“FeLV”), & heartworms.
• I understand if the Cat is pregnant, the pregnancy will be terminated at surgery.
• I understand that if an open umbilical hernia is found, it will be repaired at the time of surgery at an additional charge of $20 to 
$40. 
• I understand -that if fleas are found on the Cat, Capstar/Nitanpyram will be administered to the Cat for the protection of the 
other cats on the truck at an additional charge of $5.
• I understand that if the Cat has undescended testicles, pregnancy, hydrometra, or hernia, there will be additional charges.
• If an emergency occurs, I consent that the attending veterinarian may perform such treatment or transport the Cat to another
veterinarian for the provision of such treatment at my expense, without seeking additional authorization or consent from me. 
THE ANIMAL WILL RECEIVE A SMALL TATTOO ON HIS/HER UNDERSIDE TO SHOW THAT HE/SHE HAS BEEN STERILIZED.
REQUESTED VACCINES OR SERVICES HAVE PROOF OF CURRENT RABIES VACCINATION? YES NO
VACCINES (rabies is required) __Dewormer $8 Cardboard Carrier $7
__Nobivac Rabies (1 yr) $20 __Pain Meds (add’l, recommended) $18
Pregnancy termination is $15 per 
trimester. Pain medication is required for 
2
nd and 3rd trimesters. There is a No 
Appointment fee (vet’s discretion} of $10. 
Hydrometra is $15 per grade. Cryptorchid 
(undescended testicle) is $30 to $60. 
Umbilical hernia repair is $20 to $40. 
__Nobivac Rabies (3 yr) $28 __Capstar/Nitenpyram (kills fleas) $10
__Purevax Distemper (RCP) $25 __Tapeworms (injection) $15
__Feline Leukemia (outdoor cats) $25 __Microchip (includes registration) $40
__E-Collar (recommended) $12
ADDITIONAL SERVICES __Activyl (fleas only) $12/mo
__FeLV/FIV Combo Test $35 __Revolution (roundworms, heartworms,
__Earmites (injection) $15 Ear mites, fleas $20, $18 for 3+
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE TERMS IN THIS AGREEMENT
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