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Spay / Neuter Check-In Questionnaire Form
Please complete the following questionnaire within 24-72 hours of your pet’s scheduled surgery:
Pet's Name
*
Species
*
Cat
Dog
Pet's Sex
*
Female
Male
Owner Name
*
Confirm your name, phone number, and email in case we need to reach someone the day of surgery.
Email
*
Phone
*
Pet History
How long have you had your pet?
*
Where did you get your pet?
*
Has your pet been healthy within the last 2-3 weeks?
*
Yes
No
Please explain your pet's health issues in the last 2-3 weeks.
*
Any vomiting/diarrhea within the last 24hrs?
*
Yes
No
Any coughing or sneezing within the last 24hrs?
*
Yes
No
Does your pet have any health conditions we should know about?
*
Yes
No
Please list your pet's health conditions we should know about.
*
Does your pet take any medications?
*
Yes
No
Please list your pet's medications.
*
Current flea preventative?
*
Yes
No
Current heartworm preventative?
*
Yes
No
Would you like a heartworm test for $75?
*
Yes
No
Has your pet traveled outside of San Francisco in the past 2 years?
*
Yes
No
Where did your pet travel?
*
Has your pet been in heat recently or had puppies/kittens?
*
Yes
No
How long ago was your pet in heat or had puppies/kittens?
*
Does your pet have a microchip?
*
Yes
No
Would you like to add on a microchip for $30?
*
Yes
No
Vaccine History
Has your dog received a DHPP vaccine?
*
Yes
No
Date of last DHPP vaccine:
*
MM slash DD slash YYYY
Date next DHPP vaccine is due:
MM slash DD slash YYYY
Leave blank if unsure.
Would you like to add a DHPP vaccine during your visit?
*
Yes
No
Has your dog received a Rabies vaccine?
*
Yes
No
Date of last Rabies vaccine:
*
MM slash DD slash YYYY
Date next Rabies vaccine is due:
MM slash DD slash YYYY
Leave blank if unsure.
Would you like to add a Rabies vaccine during your visit?
*
Yes
No
Has your dog received a Leptospirosis vaccine?
*
Yes
No
Date of last Leptospirosis vaccine:
*
MM slash DD slash YYYY
Date next Leptospirosis vaccine is due:
MM slash DD slash YYYY
Leave blank if unsure.
Would you like to add a Leptospirosis vaccine during your visit?
*
Yes
No
Has your dog received a Bordetella vaccine?
*
Yes
No
Date of last Bordetella vaccine:
*
MM slash DD slash YYYY
Date next Bordetella vaccine is due:
MM slash DD slash YYYY
Leave blank if unsure.
Would you like to add a Bordetella vaccine during your visit?
*
Yes
No
Has your dog received a Canine Influenza vaccine?
*
Yes
No
Date of last Canine Influenza vaccine:
*
MM slash DD slash YYYY
Date next Canine Influenza vaccine is due:
MM slash DD slash YYYY
Leave blank if unsure.
Would you like to add a Canine Influenza vaccine during your visit?
*
Yes
No
Has your cat received a FVRCP vaccine?
*
Yes
No
Date of last FVRCP vaccine:
*
MM slash DD slash YYYY
Date next FVRCP vaccine is due:
MM slash DD slash YYYY
Leave blank if unsure.
Would you like to add a FVRCP vaccine during your visit?
*
Yes
No
Has your cat received a Rabies vaccine?
*
Yes
No
Date of last Rabies vaccine:
*
MM slash DD slash YYYY
Date next Rabies vaccine is due:
MM slash DD slash YYYY
Leave blank if unsure.
Would you like to add a Rabies vaccine during your cat's visit?
*
Yes
No
Has your cat received a Feline Leukemia vaccine?
*
Yes
No
Date of last Feline Leukemia vaccine:
*
MM slash DD slash YYYY
Date next Feline Leukemia vaccine is due:
MM slash DD slash YYYY
Leave blank if unsure.
Would you like to add a Feline Leukemia vaccine during your visit?
*
Yes
No
Would you like for your cat to receive an FeLV/FIV test today for $50?
*
Yes
No
You Can Help Support Our Work
We can’t do it without you! Our Spay/Neuter Clinic fees are significantly less than those charged at private veterinarians’ offices. Making this surgery available to everyone is vital to our mission of ending animal abandonment in San Francisco.
Please consider even a small donation on top of your surgery fee. By adding a $10, $25, or even $50 donation to your spay/neuter fee, you help us keep our costs low. Thank you!
Would you like to make a donation to support our work?
Yes
No
Thank you for your support! How much would you like to give?
*
We won't process your donation until the day of your appointment.
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