HSWC Surgical Request Form

Please be sure to fill out each field completely and accurately. Failure to do so may result in delay in scheduling.

Printed Name of Responsible Party

Address, City, Zip and 2 Phone Numbers

Please include all of the above and at least two phone numbers (yours and an emergency contact in case you can not be reached).

Email Address

I believe I qualify for your Low Income Spay/Neuter Program and will attach a determination letter from a state program dated within 6 months. (Please refer to information on our website.)

File / Image upload

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2nd File / Image upload

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Species, Name of Pet, Age, Gender, Description, WEIGHT, List Services Requested for each animal. If they are overweight or have health issues, inform us of that here.

Please be specific and give all information requested. List of services and fees available on our website.

Date

2025

Surgical Information

Please select to acknowledge understanding of the procedures you are requesting.

Cat Neuter procedure is performed under injectable anesthesia. An incision is made over each testicle. The testicles are removed and the incisions are left to heal on their own. If both testicles are not descended, an abdominal incision to locate them may be required.

Dog Neuter procedure is performed under general anesthesia. An incision is made ahead of the scrotal sac. The testicles are removed and the incision is sutured using dissolvable sutures. If one or both testicles are not descended, an abdominal incision to locate them may be required.

Cat/Dog Spay is performed under general anesthesia. An incision is made into the abdoment in the mid-belly region. The ovaries and uterus are removed. The abdominal muscles are sutured with dissolvable sutures. The outer skin is generally closed with glue. If external sutures are used, you will be provided with instructions.

Other:

You must read and choose BOTH boxes before signing.

The nature and purpose of these procedure(s) or treatment(s), the associated major risks and available alternative treatments have been explained to me. I acknowledge that no guarantee has been made as to the results that may be obtained, I understand that complications may arise which cannot be predicted. I understand that I will be financially responsible for any veterinary medical care necessitated by complications. If unforeseen conditions arise which, in the judgment of the attending veterinarian, call for procedures or treatments other than those now being authorized, I authorize such procedures or treatments if reasonable efforts to contact me for further consent are unsuccessful. Animals found to be pregnant will be spayed without further consent. It is important to recognize that anesthesia has an inherent risk associated with its use. Anesthetic: complications and fatalities are uncommon, especially in young and healthy animals, however, complications cannot always be predicted or prevented. I hereby authorize the agents of the Humane Society of Waupaca County, Inc. to administer anesthetic to animals listed on this form or attached to this form. I realize that unforeseen complications may arise during or after anesthesia, and I authorize the veterinarian in charge to provide supportive care as needed. I understand that I will be financially responsible for any and all potential complications. I acknowledge that I have carefully reviewed all the information above. Furthermore, I understand that I should not sign this release for if I have any unanswered questions or concerns.

I have read all the information, consent to the requested procedures and conditions and agree to pay any balance due when picking up my animal(s).

Signature