Semen release

FROZEN CANINE SEMEN RELEASE FORM

INTERNATIONAL CANINE SEMEN BANK –WISCONSIN

This form must be completed by the semen owner and submitted to ICSB-Wisconsin BEFORE frozen semen can be released. Please submit this form to arrive at least 3 days before requested shipping date. If notice is less than three days, a stat fee will apply as follows: 2 day: +$15.00, 1 day: +$45.00 Same day: +$55.00

___________________________________ ___________________________ _____________________

Registered Name of Dog Breed Registry and Number

ICSB-WI File Number______________

Ship to: Name_________________________________ Phone # ____________________

Veterinary Facility________________________________________________________

Address________________________________________________________________

____________________________________________________________

Zip/country code_______________________________________________

For use by: Bitch Owner___________________________ Phone # _______________________

Address_________________________________________________________________

__________________________________________________________________

Zip/country code_____________________________________________________

Registered Name of bitch to be bred________________________________________

Registry & Number ________________________

Charges are to be billed to (Visa/Mastercard) number___________________________ Exp_________

Your credit card will be charged prior to shipment

Name on credit card__________________________________________________________________

This shipment is insured to cover the shipping tank replacement in the event of damage/loss during shipping. Additional insurance to cover the value of the semen may be purchased at the rate of $0.50 per $100.00, however, a claim may not be honored by the shipping company since the semen is considered perishable goods. If desired, please indicate the amount you wish to insure the shipment: $________________.

Signature of semen owner_________________________________________ Date____________

Printed name of semen owner______________________________________ Phone__________

Address_________________________________________________________________________

BROWNSVILLE/LOMIRA SMALL ANIMAL CLINIC LLC Client Name ___________ #______

AUTHORIZATION FOR SURGERY AND ANESTHESIA          Pet Name     __________________

Anesthetic and surgical procedure(s) to be performed: (All patients will have an EKG and blood test run in advance of anesthetic induction)

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am____I am not___ (check one) eighteen years of age or over and authorize the veterinarian(s) at Brownsville/Lomira Small Animal Clinic LLC to perform the above procedure(s).  I understand that some risks always exist with anesthesia and\or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.  My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

·         The reasonable medical and\or surgical treatment options for my pet.

·         Sufficient details of the procedures to understand what will be performed.

·         How fully my pet will recover and how long it will take.

·         The most common and serious complications.

·         The length and type of follow-up care and home restraint required.

·         The estimate of the fees for all services.

·         Any necessary payment arrangements.

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.  I agree to provide payment via cash, credit card, or check at the time my pet is discharged from the hospital.  Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff has___ does not have___(check one) my permission to provide such treatment and I agree to pay for such services.

I understand that veterinary care during nighttime hours and\or weekends is provided at the discretion of the attending veterinarian.  Continuous presence of personnel may not be provided during these hours. Please be aware that as allowed in Wisconsin Statutes and Administrative Code VE 7.02 some services may be provided by a veterinary student, certified veterinary technician or an unlicensed assistant.  I realize that in many cases, it is impossible to determine in advance the extent of medical or surgical treatment required for an animal.  In such cases, staff from the Brownsville\Lomira Small Animal Clinic, LLC will attempt to estimate the cost of treatment, but it is understood that the actual cost may exceed or be lower than this estimate, depending upon the extent of treatment required.

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Signature of Owner or Agent                          Date                            Staff initials___________06-07 IP SX 005

____________________________________________        qPlease call me with an update on my pet  

Telephone where I can be reached today during procedure qPlease call me at work only if urgent         

____________________________________________        qDo not call me at work                               

E mail address________________________________        You may call about your pet today at 920-269-4072