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DLG Appt Form 6/21
Alaska Rural Veterinary Outreach, Inc.
Request for Appointment
Please provide the following information to the best of your knowledge, and we will get back to you by phone or email.
Submitting this form is not a guarantee for an appointment, but we will do our best to help as many pets as possible.
KOTZEBUE, AUGUST 16, 17, 18, 2019
Location: 240 5th Street, Kotzebue AK 99752
You must complete a separate form for
Indicates required field
Pet Owner's Name
About Your Pet
Your Pet's Name
Dog or Cat
Male or Female
(state months or years)
Breed (if known, or your best guess)
Approx. Estimated Weight
Check the services you want:
Spay Surgery - Females, no more unwanted litters
Neuter Surgery - Males, no more making puppies
Additional comments, input or questions - any particular health concerns for your pet?
RELEASE OF LIABILITY
BY SUBMITTING THIS REQUEST FOR APPOINTMENT
, I declare the following: that I am the above-named owner of this pet, being a person over eighteen years of age. I hereby authorize Alaska Rural Veterinary Outreach, Inc. (ARVO) to administer anesthesia and perform surgical sterilization, vaccination(s) and/or additional procedures as requested by me and deemed appropriate, as determined by medical evaluation to the above named pet.
I have read and understand the following:
the veterinary medical resources available in a rural setting are limited; the physical examination received by my animal is basic, does not include blood work, and is not intended to detect all illnesses or injuries that may be present;
there are inherent risks in receiving medications, vaccinations or any surgical, anesthetic or other procedure, up to and including the risk of death, and these risks have been explained to me;
some factors significantly increase the likelihood of these risks, including pregnancy, heat, overall poor health, malnutrition, and pediatric or geriatric age, and these risk factors have been explained to me;
ARVO reserves the right to decline surgery or any procedures, treatments or medications that it feels are unsafe or inappropriate for the animal.
I fully and completely understand the risks and risk factors present here, and despite same hereby request that ARVO proceed with the procedure(s), medication(s) or vaccination(s) I have requested.
I hereby release and discharge ARVO, and its employees, agents, volunteers, veterinarians, technicians, staff, officers, directors and consultants, and agree to indemnify, defend and hold them harmless, from any and all liability for loss or injury of every kind or nature that in any way arises, results from, or relates to participation in this clinic. This specifically includes release of all claims of liability based upon the negligence, or future negligence, of ARVO, and its employees, agents, volunteers (including veterinarians and technicians), staff, officers, directors and consultants, and includes but is not limited to any claim based upon a failure to meet any standard of care. I understand that this means that I will not be able to sue or bring a claim of any sort against any of those individuals and entities being released herein.
Please let us know if we may use photos taken of you and/or your pets at this clinic. Thank you.
Yes, you may use photos of me and/or my pets.
No, you may not use photos of me and/or my pets.
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Alaska Rural Veterinary Outreach,
1120 Huffman Rd., #24-783
Anchorage, Alaska 99515
IRS Tax ID# 45-4779560
ARVO is a registered
charity with the
Alaska Dept. of Law