VAP SPAY/NEUTER ASSISTANCE PROGRAM APPLICATION

VAP SPAY/NEUTER ASSISTANCE PROGRAM APPLICATION
Ifyou live in North Bend, Snoqualmie or Fall City and own a cat or dog and cannot afford the surgery, we provide certificates for spay or neuter surgeries at approved Veterinary Clinics. Co-pay required.
Co pay Amount
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Email Address
Address

Street

Street Address Line 2

CityState

Zip Code
Home Phone
Mobile Phone
PET INFORMATION
CatDog
Pet's Name
Breed
Mixed Breed?

YesNo
Age
Color
Weight
Gender

MaleFemaleUnknown
Has this animal been to a Veterinarian?

YesNo
Approximate date of last visit

MonthDayYear
Date
Clinic Name / Location
Has this animal received vaccinations?

YesNo
Date Last vaccinated

MonthDayYear
Date
If Female, has she had any litters?

yesno
How many litters?
Date of most recent litter

MonthDayYear
Date
Where does this animal stay / sleep?
Is this animal licensed?

yesno
How did you acquire this animal?
What city / state did you acquire this animal?
Are you planning on keeping this animal?

yesno
Are there circumstances that we need to be aware of (ie. Termination of pregnancy, pediatric spay, un-descended testicle, etc that would make the procedure more costly or hazardous to the animal? If yes, please explain below:
Explain here:
GENERAL INFORMATION
Gross annual income
How many dependents in the household?
Do you need assistance with transportation to the surgery appointment?

yesnomaybe
Do you have other dogs or cats that need to be spayed/neutered? If so, include animal type, age, gender and approximate weight and we will try to provide additional assistance
Please list public assistance program, if any, you participate in: (copy of documentation required)
Date

MonthDayYear
Date
VAP covers the costs related to spay/neuter surgery. VAP doesn’t cover routine care such as vaccines. Please note that the rabies vaccine is required. If you need help with the cost of vaccines, please let us know. In addition, VAP does not cover a pre-surgery blood panel on young, healthy dogs. The veterinarian may ask you if you want to pay for the blood panel. You can decline this blood panel. If it appears to be necessary before surgery, please let us know. I hereby certify that the information provided in this application is true and correct to the best of my knowledge.

Clear
For Internal Use Only Certificate Number
Certificate Number
Date Issued

MonthDayYear
Date
Date Used

MonthDayYear
Date
(Vet Clinic
Should be Empty:

VAP SPAY/NEUTER ASSISTANCE PROGRAM APPLICATION

PET INFORMATION

GENERAL INFORMATION