Date _____________________ Frankie’s Friends Feline Surgical Intake Form

Owner/Caregiver Name ________________________________________________________

Street Address _______________________________________________________________

City, State, Zip________________________________________________________________

Home Phone____________________________ Cell Phone ___________________________

Cat’s Name __________________________________ Breed __________________ Approx. Age _______

Gender ________________ Color/Markings___________________________________________________

Please select from the following: Spay/Neuter Other_________________________________

Ear Tip (for feral/stray cats to be released back into colonies) No Ear Tip

All cats get an injection for pain, an antibiotic injection, flea treatment, and ear mite treatment (if needed) at no
additional cost with spay/neuter surgery. Rabies vaccination is mandatory, in the state of Pennsylvania, for cats
over 3 months of age. We will administer a Rabies vaccine, free of charge, to all eligible cats (including
underage community cats) unless a certificate is shown on check in. Rabies certificates will be issued if
cats are verified to be 12 weeks of age or older.

Please select any additional services below:

Profender Worm Medication ($15) Feline Leukemia/Feline Immunodeficiency Virus (FIV)Test ($25)

Feline Leukemia Vaccination ($12) Feline Distemper Vaccination (FVRCP) ($10)

Other___________________________________________________________________________________

Medical History Total Due ____________

Has your pet been in good health the past two weeks? _______

Is your pet on any medications? ______ What Medications? _______________________________________

Additional Concerns/Medical History __________________________________________________________

l, being responsible for the animal described above, have the authority to grant the veterinarian my consent to
receive, treat, anesthetize, and/or perform surgery upon the animal named above.

I understand there are risks inherent to anesthesia and surgery. I understand that the patients do not undergo
a pre-anesthetic evaluation and I accept the risks of any underlying health problem that would complicate
survival/recovery from anesthesia and surgery.

I agree to hold harmless and indemnify Frankie’s Friends, their officers, their volunteers and their employees
from any loss, injury or damages arising out of or in any way connected to the services requested herein.

My signature acknowledges that I have read and fully understand the terms of this agreement.

Caretaker/Agent Signature ________________________________________________________

Patient Number __________________ Frankie’s Friends Feline Surgical Record

Animal Name _________________________________ Gender _______ Age _______ Weight _______#

Pre-op: TDK ______/______/______ or Ket__________ / Mid__________

Body Condition: ____________________________ FeLV ________/FIV _________

URI Conjunctivitis Corneal Scaring Oral cavity _______________ Wounds ___________

Fleas Ticks Lice Ear mites Tapeworms Diarrhea

Other Comments_______________________________________________________________________

Surgery: Routine Castration Routine Spay Already spayed/neutered Pregnant Lactating

Dental Other ___________________________________ Ear tip __________

Comments_________________________________________________________________________

Place Rabies
Medication/Treatment: Penicillin Meloxicam Buprenorphine ______cc Sticker Here

Profender Flea Meds Ivermectin SQ Fluids _________cc Place FVRCP

Sticker Here
Other__________________________________________________________
Place FeLV
Meds need sent home __________________________________________ Sticker Here

Recovery: Normal Recovery Prolonged Recovery Other __________________________________

Go Home Instructions: _____________________________________________________________________

________________________________________________________________________________________

Discharge: Time of Discharge ______________

Caretaker given discharge instructions, vaccination certificate (if applicable), and

medications (if prescribed).

__________ (Initial)