Volume Client

Primary Contact Information

Volume Client Organization

Date

Main Contact- First name

Main Contact- Last name

Organization street address, city, state & zip code

Main Contact- Phone

Main Contact- Email

Who should we contact for Medical emergencies?

Secondary Contact

Name, phone number & email

Billing Email if different

Email for Rabies, Microchip & Surgery certificates if different

Are you a 501(c)(3)?

Organization's Website

Dog Sellers License number

Please send CVI copies

With the dog that day

Email a copy and also send it with dog

Mail a copy to the address above

Email a copy and mail it to the address above

Rabies certificates that include vet name and serial number of vaccine are required for a CVI certificate in dogs over 5 months of age. If we do not have attached proof when a CVI is requested and are not vaccinating the dog that day:

DO NOT revaccinate, no CVI will be issued.

Revaccinate for Rabies

Please list any additional people allowed to make medical decisions by name and/or by title such as foster.

Surgical Consent

All surgeries & use of anesthetic drugs present some risk of complication, possibly including injury/death. In the event of an emergency (respiratory or cardiac arrest) WCVC staff will contact you. In this event, for all animals undergoing surgery:

YES, please perform CPR. We will cover any costs incurred.

NO, DO NOT RESUSCITATE. We understand the animal likely will not survive.

If we are UNABLE to perform a pre-surgical exam on this patient due to behavior, may we proceed with surgery?

Yes

No

If an animal presents for surgery and a suspected spay scar is discovered once they are sedated and prepped, would you like us to:

Surgically confirm they are spayed.

NOT perform surgery & wake the animal up.

Always contact us first for each animal.

If an animal presents for surgery and retained testicle(s) are discovered once they are sedated and prepped, would you like us to:

Perform the surgery including locating the missing testicle(s).

Do not continue, wake the patient up.

Always contact us first for each patient.

If an animal presents for surgery and an umbilical hernia is discovered once they are sedated and prepped, would you like us to:

Repair the defect at additional cost.

Do not repair the defect.

Always contact us first for each animal.

* I understand that selecting “contact me first” options may mean re-sedating the animal at a later date if we are unable to reach you immediately. Any additional costs will be the responsibility of the volume client.

Take-home pain medication is required for spay/neuter services. Shelters with stock supplies from their vets are not required to purchase our pain meds.

We need pain medication sent home with each animal.

We have a stock supply of pain medication and can provide proof of prescription upon request.

If an animal presents for surgery and additional minor medical conditions are found needing attention such as ear or skin infections or masses etc. that should have a cytology do you consent to treatments automatically:

Up to $50

Up to $100

Always contact us first for each patient if over $100

Any amount, I give full consent

No additional amount approved until verified by rescue or shelter

No additional services

Payment Preferences

I understand that services must be paid for as they are rendered and will pay after each invoice is sent. Payment can be made by credit card, check or a payment link can be sent. A 3% surcharge fee may be added to all credit card transactions.

Our organization will provide payment by check after invoicing.

Send me an invoice link.

Keep our credit card on file. I authorize WCVC to process payments as services are rendered.

I would like to set up portal access and pay by credit card through my portals.

Card Number

Expiration

3 digit CSC

Name on Card

I understand that invoices not paid as agreed will result in suspended services and possibly collections . I understand that WCVC has the right to withhold all ongoing services, lab results, and records until any dispute is resolved.

El campo de firma está vacío.

I understand that an administrative fee may be charged for any/each appointment reserved but not used if at least 3 days notice was not given.

El campo de firma está vacío.

I understand that WCVC has the right to refuse services to any animal to whom it has deemed a health risk. I will inform WCVC of any health concerns I am aware of.

El campo de firma está vacío.

I understand that WCVC is a teaching facility and that training veterinarians, veterinary technicians and 4th year vet students participate in externships at this clinic while working directly under the supervising veterinarian.

El campo de firma está vacío.

I understand that a 4th year veterinary student, training veterinarian or veterinary technician may, under the direct supervision of a licensed veterinarian, participate in and/or assist with procedures or treatments.

El campo de firma está vacío.

I give permission to doctors, staff, authorized agents, or representatives of WCVC to examine, prescribe for, and treat my pets. I hereby release WCVC, any employee, or any volunteer from any and all claims arising from future visits.

El campo de firma está vacío.

I understand that WCVC will spay females in heat or pregnant. I know this will prolong surgery time and have higher risk of bleeding. If I do not want a suspected pregnancy terminated I will not bring the animal knowing the pregnancy will be terminated.

El campo de firma está vacío.

I understand that there may be times a photo or video of our animals may be used on WCVC and/or SFTS's social media sites and webpages.

El campo de firma está vacío.

Feel free to add any additional information you would like us to know.

Volume Client Application

Primary Contact Information

Secondary Contact

Surgical Consent

Payment Preferences