Cat Clinic Sign Up Cat Clinic Sign Up If you are human, leave this field blank. Phone Number * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Preferred Clinic Date Option 1 Option 2 Name * Email Address * Cat's Color * Cat's Coat Length Short Hair Medium Hair Long Hair Cat's Name * Cat's Gender * Male Female Cat's Age * Do you have any concerns about the health of your cat? If so, please make us aware. Authorization Agreement * I hereby authorize Dr. Dowty to examine, prescribe for, or treat the pet described above. I assume responsibility for all charges incurred. You are to use all reasonable precautions against injury, escape, or death of my pet, but you will not be held liable or responsible in any manner and it is thoroughly understood that I assume all risks. By signing or typing your name in the signature field below you agree to and authorize the above agreements. * Clear Check the fee services that you would like for your cat: Male Neuter - $39.00 Female Spay - $59.00 Female Spay Pregnant - $79.00 1 Year Rabies Vaccination (Required - or rabies certificate must be provided) - $8.00 FVRCP (Recommended - Feline Viral Rhinotracheitis/Calicivirus/Panleukopenia) - $10.00 Wormer - $3.00 Flea Preventative - $5.00 Ear Mites - Cleaning and Tresiderm - $25.00 Ear Notch/Tip - $3.00 Feline Leukemia/AIDS Test - $30.00 Pre and Post Surgery Instructions Agreement * I will bring my cat indoors the night before surgery, provide a litter box and remove all food before midnight. I will have water available throughout the night. I understand that after anesthesia, my cat won’t be able to regulate his/her body temperature. I will provide a place in my home, with a comfortable temperature and a litter box for at least 3 nights. Check the complimentary services that you would like for your cat: Nail Trim - Indoor Cats Only Total Paragraph