Fix-It Application Form

A partnership between Elmbrook Humane Society and Animal Doctor of Muskego

Owner Information:
Name * Required
First Last
Address * Required
Street Address City State ZIP Code
Email: * Required
Daytime Phone #:
Pet Information
Select One: * Required
- Dog
- Cat
Sex: * Required
- Male
- Female
Breed: * Required
Name: * Required
Age - Year * Required
Please enter a number from 0 to 20.
Age -Month * Required
Please enter a number from 0 to 12.
Weight: * Required
Has your pet been seen by a Veterinarian? * Required
- Yes
- No
When? - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY

List of any diagnosed problems your pet has: *

Click "+" to add more diagnosed problem

List of any medications your pet is taking: *

Click "+" to add more medications your pet is taking.

Is your pet showing any signs of illness or disease? * Required
- Yes
- No
Please describe any signs of illness or disease? * Required
Where was your pet acquired? * Required
How did you find out about this program? * Required
I am the owner and authorized agent of the above described pet and authorize Animal Doctor of Muskego to perform sterilization procedure on my pet. I authorize the attending veterinarian to vaccinate the above described pet for rabies and distemper and if my pet is a dog, test my dog for heartworm. I authorize the attending veterinarian to prescribe, dispense, and treat for post surgical pain associated with the sterilization procedure. I hereby authorize the use of anesthetics as the veterinarian deems advisable and performance of the surgical procedure. I understand that all surgical procedures have some potential risks, including the possibility of death. I agree to hold Elmbrook Humane Society and Animal Doctor of Muskego harmless from any liability arising from the proper performance of this procedure.
Signature * Required
Date: - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY

Owner Information: