Test Form – Oregon Coast Humane Society

Personal Information

Name

First

Last

Email*

Primary Phone Number

Work/Message Phone Number

Physical Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Mailing Address (if different)

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Animal Information

Type of animal

Cat

Dog

Animal's Name

Age

Sex

Color/Pattern

Breed

Does this animal have any history of recent or ongoing illness or previous vaccine reaction?

Yes

If Yes, Please Describe:

Please Read and Agree to the Following

I, being of legal age and responsible for the animal above, have the authority to grant OCHS and its agents my consent to receive, transport, prescribe for, treat and perform surgery upon the animal above. I understand that modern techniques and trained staff will be used to care for all animals, and reasonable precautions will be used against injury, escape, or death of the animal. Animals are treated with NSAID pain medications, which, for cats, may be in an extra label but low dose that is generally accepted as safe. As with all medications and vaccines, adverse reactions are possible. It is understood that OCHS and it's agents will not be held liable for unwanted results. Surgery and anesthesia have inherent risks, and individual animals may respond in unpredictable ways.

Required*

I Agree

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