Name:____________________________ Appt. Date:____

Address:___________________ City:______________ State:________ Zip:__________________

Day Time Phone:____________ 
Evening Phone:_____________Cell Phone:_____________

Pet's Name:___________ Approx. Age:______ Gender: M/F Color______ Breed______________________

E-Mail:_____________________________

Services Requested

[] Spay (Females) [] Neuter (Males) [] Declaw (Cats only)
 [] Rabies [] Distemper combo

[] Eartip (Feral cats) [] Flea/tick treatment [] Ear Mite treatment []Deworm (Internal parasites) 
[] Feline Leukemia test [] Feline Leukemia/FIA Combo test

Was your pet recently treated for Fleas/Ticks?_____ Date of treatment _____    Product used__________________

General Information

How did you acquire this pet? []Adopted from Forgotten Feline & Fidos        [] Friend/Relative/Neighbor

[] Stray             [] TNR (trap, neuter& return) cat
 [] Other______________________

I appreciate your organization's efforts to help animals and would like to make a donation: $_

I believe that my pet is healthy and has no known health issues currently. Because this is a low cost program, I am aware that no physical exam will be conducted on my pet prior to administrating anesthetic drugs and surgery.

I understand the anesthetic and surgical procedures may involve risk of complication, injury or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure. Furthermore, I authorize the Forgotten Feline staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communication with me. I agree to assume financial responsibility for all routine and emergency services rendered.   In the event of complications I will not hold Forgotten Feline and Fidos, their staff nor their veterinarians conducting the surgery responsible. I will be responsible for all expenses incurred with this pet after it is discharged.

I am also aware that if Forgotten Feline staff finds evidence of fleas, ticks, ear mites, lice or internal parasites they will treat the pet accordingly and I will be responsible for all cost of medicines used or administered. This cost will be collected on discharge of the pet.

Your signature below indicates your acknowledgement that you have read and agreed to the above procedures and that you have all the information you desire and you have had a chance to ask questions and you authorize and consent to the performance of the procedures and administration of anesthesia.

All pets must be picked up at the times give you by Forgotten Feline Staff. No exceptions and boarding fees will be added for late pick-ups.