VSB

Virtual Sugesstion Box

Pet Owner/Authorized Agent's First Name:
Please Submit One Form For Each Pet

Pet Owner/Authorized Agent's Last Name:

Primary Phone:

Email:

Address:

City:

State:

Zip:

Dog or Cat?:

Pet's Name:

Pet's Age:

Pet's Breed:

Pet's Sex:

Pet's Color:

Pet's approximate weight:

Is your pet spayed or neutered?:

Notes:


Do you want your DOG to receive a Bordetella vaccine during dental visit?:

Do you want your DOG/CAT to receive a Distemper/ FVRCP vaccine during dental visit? :

For pet's over 4 months of age, do you want your DOG/CAT to receive a Rabies Vaccination during dental visit? :

There is a small risk of vaccine reactions that some animals may experience. Most common are lethargy, mild discomfort or swelling at the injection site, slight fever, hives or facial swelling. By checking the box below, you understand those risks and authorize HSTC to administer the requested vaccine(s) to your pet:

Do you want your pet to receive a Microchip Implant during dental visit?:

Emergency contact other than yourself, to register on the microchip:
Emergency Contact First Name:

Emergency Contact Last Name:

Emergency Contact Phone Number:


Dental Pricing and Fee Schedule (listed on website)
By checking this box, I understand that if my pet needs extensive dental work and becomes cold under anesthesia, or length of time under anesthesia become too great for my pet's safety, the veterinarian has the right to stage the dental in 2 phases. The patient would have to return at a later date for the 2nd stage of the dental. All new fees would apply, minus $100 included in the initial dental fee for bloodwork.:

Once your pet's teeth have been cleaned, we will have a better understanding of the necessity of radiographs or extractions. We will need to be able to contact you for permission to perform these procedures. Please be available to answer the phone. If you decline these procedures now, and we are unable to contact you with an immediate answer during anesthesia, we can only perform what you have already approved. You understand this may result in diseased teeth being left, and you will need to follow up with your primary DVM, or schedule a procedure with us at a later date, at your own expense. Leaving diseased teeth may result in continued pain, foul odor, or infection for your pet and is not recommended. Checking this box acknowledges understanding of this statement:


Please choose ONE option
I DECLINE dental radiographs and extractions without verbal permission and a cost estimate. I understand my pet may be awoken after dental cleaning and polishing without the extraction of diseased teeth if I am unable to be reached via telephone immediately during my animal's anesthesia.:

I approve dental radiographs and/or extractions without further verbal permission with the maximum amount listed below. If further extractions are recommended, I understand my pet may be awoken after dental cleaning and polishing without the extraction of diseased teeth if I am unable to be reached via telephone immediately during my animal's anesthesia.:

If yes above, list maximum spend amount ($50-$750):

I approve dental radiographs and all extractions recommended by the DVM without further verbal permission. (Amount will not exceed $750.):


Statement
By checking the box below, I understand that I will be responsible for paying for the full additional bill (dental radiographs +/- extractions) before I may pick up my animal from HSTC today.:

Owner/Authorized Agent Typed Signature:

Owner/legal agent, please initial, sign and date below:
As the Owner / Authorized Agent on behalf of the owner of the above referenced pet, I hereby authorize the veterinary staff of the Humane Society of the Treasure Coast, Inc. to examine, draw blood, perform dental surgery, trim nails, vaccinate, administer analgesia and microchip my pet as designated by my choice. Check box to agree:

I understand that anesthesia and surgery involve some risk and potential complications. I authorize the Humane Society veterinary staff to provide any emergency procedures that may be necessary during the pre-operative, operative, and post- operative period. I assume all risks with procedure(s) performed and any related post-operative and/or follow up care. Check box to agree:

I further understand that the Humane Society staff does not provide any follow up or emergency care for my pet. Should follow up or emergency care be required, I will contact my own veterinarian or Pet Emergency and Critical Care, 2239 S. Kanner Hwy, Stuart at 772-781-3302. Any and all follow up care is at my own cost. Check box to agree:

The Humane Society of the Treasure Coast, Inc., and/or its designee will use all reasonable precautions against injury, escape or death of my animal. I will not hold the HSTC and/or directors, employees, agents, subcontractors, contracted veterinarians, or volunteers responsible under any and all circumstances for any injury, escape or death of my animal. Check box to agree:

I understand that while the recommended bloodwork can help identify some underlying conditions and minimize risks, it is not a comprehensive profile and does not guarantee complications will not occur. I understand that if my pet is having bloodwork performed, this test is a screening test and not a comprehensive profile and does not identify all possible underlying conditions. Check box to agree:

I understand that pre-surgical bloodwork is necessary for sending home any medications with the patient post-operatively unless found necessary by the veterinarian. If a blood sample cannot be obtained prior to anesthesia, the patient will be sedated to collect and run the sample. Check box to agree:

I have disclosed any/all medical information and history about my pet to the best of my knowledge. I will not hold Humane Society veterinarian or veterinary staff accountable for underlying medical conditions my pet may have. Check box to agree:

I understand that the HSTC dental cleaning program has the right to refuse service to any animals on which surgery is considered a health risk. HSTC may reschedule/delay a surgical procedure based on abnormal physical exam or blood work findings. Check box to agree:

I understand that my pet must be picked up by me or the agent I have designated at the appointed time on the same day of surgery. The pet must be picked up no later than 4:00pm the day of surgery, 3:00pm on Sundays. Failure to pick up my pet will result in the animal becoming property of Martin County Animal Services. I will be responsible for impoundment, boarding and any other related fees. If I do not pick up my pet within 5 days, my pet will be considered abandoned and will be processed in accordance with Martin County ordinance and Humane Society policy. Check box to agree:

The Humane Society of the Treasure Coast also sells Martin County License Tags which are required by law if a Rabies vaccination is administered to your dog or cat. Please see an HSTC staff member for more information. (Martin County Residents ONLY). Check box to state that you understand.:

I affirm I have read and understand the information provided above before signing this document.
Owner/Authorized Agent Typed Signature:

Date:

The Humane Society of the Treasure Coast provides contractual services to Martin County; therefore, it is subject in part to public records request. This means that documentation and information provided to us may be requested by and reviewed by members of the public.

Contact Us

Humane Society of the Treasure Coast
4100 SW Leighton Farm Ave
Palm City, Florida 34990
Main Line: (772) 223-8822
Fax: (772) 220-3610
admin@hstc1.org

Journalism inquiries only: Contact Doreen Poreba at prczar@prczar.com

Registered 501(c)3 Non-Profit

Tax ID #: 59-0774235

Thrift Stores

Central Thrift Store:
3302 SE Federal Hwy., Stuart, FL 34997
(772) 286-6909

North Thrift Store:
1099 NW 21st St., Stuart, FL 34994
(772) 232-4887

Contributions:
A copy of the official registration and financial information may be obtained from the Division of Consumer Services by calling toll free (800) 435-7352 within the state or by visiting FDACS.gov. Registration does not imply endorsement, approval or recommendation by the state. Registration #CH1552.

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Tax ID #: 59-0774235

Virtual Sugesstion Box

The Humane Society of the Treasure Coast provides contractual services to Martin County; therefore, it is subject in part to public records request. This means that documentation and information provided to us may be requested by and reviewed by members of the public.

Contact Us

Registered 501(c)3 Non-Profit

Tax ID #: 59-0774235

Thrift Stores

E-Newsletter Sign Up