Greenbrier Humane Society    

P.O Box 305 Lewisburg, WV 24901

(304) 645-4775

ADOPTION AGREEMENT

Please read carefully

Adoption Date: ______________________                       Intake Number:  _________________

Animal Name: _______________________                       Surgery date: ________ Vet: _______ Breed/Color/Markings: ____________________ _______________________________________

Age: __________      Sex: _______                                                 Dog: _____                Cat: ____

Services Received:

(Some of these are not covered in the adoption price and are done at the adopters expense)

Vaccines:                                                                                 Services:

____---Bordatello               Date: _________                                ____---Bathing                                     Date: ___________

____---DA2PPv+Cv         Date: ___________                           ____---Toenails Clipped                   Date: ___________

____---FvRCCP                  Date: ___________                           ____---Frontlined                               Date: ___________

____---Rabies: #_______ Date: ___________                           ____---De-worming                           Date: ___________

                Voucher Issued: ________________                                       ____---Other: _______________   Date: ___________

____---FeLV                        Date: ___________          

Tests:

____---Parvo                        Date: ___________

____---Feline Leukemia   Date: ___________

____---Heartworm             Date: ___________

____---Internal Parasites   Date: ___________

____---Other__________ Date: ___________

Adopters Name: ___________________________________________________________________________________

Address:

___________________________________________________________________________________

City/State/Zip: ___________________________________________________________________________________

Telephone Number: ________________________________________________________________________________

Adoption Fee Amount: $_________           Ck: _____            Cash: _____        Charge: _____

Additional Services: $____________

                (MUST  be made payable directly to the veterinarian)

Statement of Adoption

I do hereby acknowledge receipt from the Greenbrier Humane Society [hereinafter GHS] the animal described above and understand that GHS makes no warranty with regard to health, temperament, or former ownership of the animal and I accept it in its present condition. Initial Here_____

GHS cannot be held responsible for any veterinarian bills or services other than those specified above and paid for at the time of adoption. Initial Here_____

I understand that this animal may not be sold or given away, but must be returned to GHS without refund (except as noted below).  It is the legal right of the GHS to reclaim any animal harmed by neglect or mistreatment and to invoke statutory civil and criminal penalties where applicable. Initial Here_____

The GHS reserves the right to make a personal inspection of the animal after adoption to ensure that it is receiving proper care. Initial Here_____

It is GHS policy that all animals adopted must be spayed/neutered before they are allowed to leave our facility. Initial Here_____

The animal(s) must have on its body at all times the following forms of identification: an ID tag bearing the name and telephone number of the owner, a current WV rabies tag and county tax tag (dogs only). Initial Here_____

REFUND POLICY: Should the animal described above become ill or die within 48 hours of adoption, and proof of such is submitted to GHS, a full refund of adoption fees will be made.  If the animal is kept beyond the 48-hour period and no report made to GHS of illness or death, NO REFUND WILL BE GIVEN.  Initial Here_____

Procedure/Surgical Consent

Dr. Mary Ann Mann-Lewisburg Vet. Hospital                                                        Lewisburg                            645-1434

Drs. McHale, Gibson & Wall-Seneca Trail Vet. Hospital                                      Lewisburg                            645-1700

Drs. Wilson, Lightner, Mohler, Baum, Karessel-Greenbrier Vet. Hosp            Lewisburg                            645-1476

Dr. Amy Wasalaski                                                                                                           Frankford                             497-2780

I hereby authorize the above treatment/surgical procedure(s) on _______/_______/________.

Like you, our greatest concern is the well-being of your pet.  Before putting your pet under anesthesia, the veterinarian will perform a complete physical exam.  If any problems are noted, the surgery may be postponed.  The veterinarian who treats your pet will retain a copy of the medical records pertaining to her/his treatment.

The undersigned adopter understands the nature of the procedures or operations to be performed and that unforeseen conditions may be revealed or develop that require additional treatment.  The undersigned adopter consents to and authorizes the performance of such procedures or operations as are necessary and desirable in the exercise of the veterinarians judgment. 

The undersigned adopter is aware of the risks associated with the procedures or operations they have authorized to be performed on their pet.  The adopter understands the general risks involved and agrees to waive any liability on behalf of the veterinarian of GHS. 

The undersigned adopter understands that pre-anesthesia blood work may be necessary prior to surgery and/or completed as part of a physical exam.  The results can reveal information that may be helpful in detecting problems with the pet and can be especially important prior to any surgical procedure or undergoing anesthesia. 

I do___ do not____ request pre-anesthetic blood work on my pet (the cost of such blood work to be borne by the adopter).

The undersigned adopter assumes full financial responsibility for all services rendered.

Adopter Signature: ________________________________                                 Date: _________________________

GHS Representative: _______________________________                               Date: _________________________

NOTICE

Although we de-worm all adopted pets, we cannot guarantee the pet to be free of intestinal parasites.  We HIGHLY recommend that your new pet be taken to the veterinarian of your choice within 30 days of adoption for a fecal test as well as a health checkup.

_________________________________

Adopters Signature