BHS Spay/Neuter Surgery Application

BHS Roger P. Wagers Spay/Neuter & Vaccine Clinic

We are a subsidized spay/neuter program designed to provide low-cost, affordable spay/neuter surgeries and vaccines
PLEASE READ AND COMPLETE THIS ENTIRE APPLICATION AS ACCURATELY AS POSSIBLE.

If your pet has received vaccinations prior to this surgery, you MUST know your pet's vaccination history to complete this form. Please call your vet if you do not already have this information.

In order for your pet to qualify for surgery at Baltimore Humane Society, it must meet the following guidelines:

Your cat should:
- be between three months and five years of age
- weigh at least 3lbs
- have no known illness, injury, or medical conditions
- not be a smoosh-faced breed of cat (Persian, etc.)
Your dog should:
- be between four months and seven years of age
- weigh between 5lbs and 60lbs if female or between 5lbs and 80lbs if male (if your dog is less than 10lbs, they will need to receive vaccines through the Wellness Clinic prior to day of surgery to avoid vaccine reactions that sometimes arise in small dogs when combined with anesthesia)
- have no known illness, injury, or medical conditions
- NOT be aggressive towards people or other animals
- not be a smoosh-faced breed of dog (Pugs, etc.)

Your Contact Information
First Name *
Last Name *
E-mail *

Confirmation Email
Phone Number *

Area Code Phone Number
Cell Phone *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Do you qualify as low-income? If so, you could receive a FREE surgery and rabies vaccine!

If you live in one of the following zip codes, can prove residence, and qualify as low-income, you may qualify for a free spay/neuter surgery and rabies vaccine subsized through a MD Department of Agriculture grant. Qualifying zip codes are:

21136	21117	21133	21244
21208	21157	21158	21787
21048	21078	21085	21001
21040

You qualify as low-income if you meet one of the following three stipulations:

As the Head of Household, you make $25,000 per year or less individually
As the Head of a Family, you make $42,000 per year or less with dependents
And/Or you recieve state or federal government assistance

Some examples of documents that will prove your eligibility include:

W-2 or 1099
most recent tax return
two consecutive pay stubs dated within the last two months
current letter of benefits (award letter) for government assistance (i.e. WIC, unemployment, food stamps/SNAP, Medicaid, SSI (supplemental security income), welfare (TANF/FIP), or SSDI (social security disability income)
Utility bill to prove residence

You will need to bring proof of address and proof of income/government assistance with you to receive a free surgery. Your government-issued ID must match the name on your tax or benefit documents.

Do you qualify as low-income and live in one of the above zip codes? *

Your Pet's Information
Pet's name *
Species *
Gender *
If male, are both testicles present?
Is this a stray or do you own this pet?
If you own it, how long have you owned this pet? *
Estimated Date of Birth (MM/DD/YYYY) *
Age of Pet (in years) *
Approximate weight (lbs) *
Breed *
Color/Pattern *
Does your pet lunge, snap, bite, growl, hiss, or scratch at strangers or at the vet? *
If yes, please explain:

Your Pet's Medical History
Has your pet ever had a seizure or chronic medical condition? *
If yes, please explain:
Is your pet in heat? *
If your pet is in heat and it's a cat, surgery can be scheduled at any time. If your pet is in heat and it's a dog, surgery must be scheduled for at least two weeks after vaginal bleeding has resolved. The average canine heat cycle lasts 10 days.
Could your pet be pregnant? *
If yes, approx. when did the breeding occur?
Has your pet recently had a litter? *
Pets who have recently had a litter should be scheduled for surgery 12 weeks or more after the birth.
Is your pet currently on medication? *
If yes, please list here:

Your Pet's Vaccination History
Baltimore Humane Society has certain requirements that must be met to receive surgery. Please consult your pet's vet records to complete this section of the application. If your pet has never been to the vet, if your pet's vaccinations are overdue, OR if you do not know your pet's vaccine history, we will administer the following:
- FVRCP vaccine (cats) ($13)
- DHPP vaccine (dogs) ($13)
- Rabies vaccine (dogs and cats) ($13)
If your dog is 6 months of age or older, they will be required to receive a heartworm test ($23) IF they have no record of a negative heartworm test in the last year.

For the health and safety of your pets and others at the clinic, these policies are not negotiable. If your pet has received any of these services at another vet within the last year, please consult your records and include specific dates on this application to avoid having to receive these services again on the day of surgery.

Due to the risk of rabies transmission to people, you MUST provide proof of your pet's current rabies vaccination at the time of drop off for surgery. Proof includes an official rabies certificate or rabies vaccination record from your vet. The rabies tag is NOT proof of rabies vaccination. If you do not have proof, your pet will be given the required rabies vaccination at surgery.

Looking at your vet records, please answer the following questions.
Do you currently have a veterinarian? *
If yes, please include their name and phone number below:
Name and contact information of your veterinarian
What is the date of your pet's last rabies vaccine? *
You must present proof of vaccination at appointment. If your pet hasn't had a rabies vaccine, please enter N/A.
According to your vet records, when is this vaccine due again? *
If your pet hasn't had a rabies vaccine, please enter N/A.
What is the date of your pet's last FVRCP or DHPP vaccine? *
If your pet hasn't had this vaccine, please enter N/A.
According to your vet records, when is this vaccine due again? *
If your pet hasn't had this vaccine, please enter N/A.
What is the date of your dog's last heartworm test?
Is your dog currently on monthly heartworm prevention?

Our Services
Please select all services that your pet needs.
Spay/Neuter services *
Adults are 6 months of age or older. Juveniles are younger than 6 months of age. If your pet is 6 months of age or older on the day of surgery, you will be charged adult pricing.
Rabies vaccines *
Rabies is required to be given if your pet is not current or has never been given this vaccine
Distemper (DHPP for dogs, FVRCP for cats) *
DHPP/FVRCP is required to be given if your pet is not current or has never been given this vaccine
Heartworm/Lyme Test (dogs)
Due to potential anesthetic risk in heart worm-positive dogs, the test is required before surgery if your dog is 6 months of age or older.
FeLV/FIV Tests (cats)
Optional, but strongly recommended if cat is an outdoor cat.

What to Expect
Before your appointment, you will:
- keep your pet indoors after 8pm on the evening before surgery
- DO NOT feed your pet after midnight the day prior to surgery. This means no breakfast or treats before surgery, either. They can have water. (Kittens are the exception—they should have a small snack for breakfast)
When you drop off for your appointment, you will:
- have your dog on a collar and leash
- have your cat in a labeled, clean cat carrier ( only ONE cat per carrier )
- arrive between 8-8:30am on the day of your appointment (regardless of appointment time scheduled online). If you are late, late fees will apply. Please allot 15-20 minutes for drop off.
- park in a spot marked by an orange cone and call the number on the placard (667-209-3980)
- wait in your car for us to come to you—we will go over your paperwork in the parking lot and retrieve your pet from your car
- pay for services at morning drop off—we accept cash or credit card
When you come to pick up your pet, you will:
- pick you pet up between 3-3:30pm with the same protocol—park by a cone, call us, and we will bring the pet to you
- if you are late to pick up, you will be charged late fees
- please allot 15-20 minutes for drop off and pick up
If you arrive with a pet that is too anxious or fearful to be handled, is in a muzzle, or otherwise deemed unhandleable, we have the right to refuse service. Additionally, if your pet is injured, ill, in heat (dog), or outside weight range (please see beginning of form) we have the right to refuse service.

Completing this application is the first step in receiving a spay/neuter surgery for your pet from Baltimore Humane Society. Once you submit this application, you will be redirected to our online scheduling tool to schedule your pet's surgery. Due to Covid-19, we have limited surgery capacity per day as well as higher demand for surgeries so there may not be immediate availability. Thank you so much for your patience!

If you do not hear from us, please check your email's junk/spam inbox or call us at 410-833-8848 ext. 209.

If you need to cancel, please call us at least 24 hours before your appointment!
I've read this thoroughly and I agree to all the services and fees selected above: *
Please type your name to sign this form: *
Please verify that you are human *
Please review your application thoroughly. Once it is completed, please press the "Submit" button below. Please only press this button one time to prevent multiple submissions. Thank you!
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BHS Roger P. Wagers Spay/Neuter & Vaccine Clinic