PMSPCA Spay/Neuter Clinic app

PMSPCA Spay/Neuter Clinic Application - Dog

Please note that we are the Pope Memorial SPCA in Concord, NH
This clinic is only for healthy dogs, weighing less than 55 pounds and aged 4 months to 5 years. To reserve a spot, please complete this application and submit your non-refundable deposit. We will review your application and reach out via email with an available appointment and pre-surgery details. Clinic drop off time is 8:45-9a and pickup before 4pm on the same day.

* Due to a large number of applications and a 1-3 month wait for an appointment, please allow us time to respond with an available clinic date. If you cannot or do not want to wait for a surgery date, please do NOT complete an application, as the application deposit is non-refundable. *
Owner Name*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
How many dogs are you bringing ?*
Maximum of two allowed per application
Dog 1 - Name*
Dog 1 - Date of birth*
Dog can only be between 4 months to 5 years; specific date required, check with your vet if unknown
Dog 1 - Gender*
Dog 1 - Weight
Must be at or under 55lbs
Dog 1 - Weight*
Must be at or under 55lbs
Dog 1 - Breed*
We cannot accept certain breeds: Cavalier King Charles, Pekinese, Lhasa, Bulldog, Shih Tzu, Boston Terrier, Pug, French Bulldog, Japanese Chin or Tibetan Spaniels (other flat faced breeds may not qualify).
Dog 1 - Color/markings*
Dog 1 - Medical conditions/concerns*
Dog 1 - How does your dog act at the vet and/or with strangers?*
Describe behavior
Dog 1 - additional vaccinations needed ? (select all that apply)

Rabies (required if not current) - $40Distemper - $30Lyme - $45Kennel cough - $30Microchip - $30Flea/Tick - $35Heartworm test - $154DX test - $35
Dog 2 - Name
Dog 2 - Date of birth
Dog can only be between 4 months to 5 years; specific date required, check with your vet if unknown
Dog 2 - Gender
Dog 2 - Weight
Must be at or under 55lbs
Dog 2 - Breed
We cannot accept certain breeds: Cavalier King Charles, Pekinese, Lhasa, Bulldog, Shih Tzu, Boston Terrier, Pug, French Bulldog, Japanese Chin or Tibetan Spaniels (other flat faced breeds may not qualify).
Dog 2 - Color/markings
Dog 2 - Medical conditions/concerns
Dog 2 - How does your dog act at the vet and/or with strangers?
Describe behavior
Dog 2 - additional vaccinations needed ? (select all that apply)

Rabies (required if not current) - $40Distemper - $30Lyme - $45Kennel cough - $30Microchip - $30Flea/Tick - $35Heartworm test - $154DX test - $35
Clinic costs are $450-550 for a spay (female) and $350-450 for a neuter (male). You may apply for an additional discount by showing proof of need. Please indicate if you plan to apply for an additional discount and submit your documentation.*

Yes, I agree to the standard costsNo, I will apply for a discount by submitting proof of my local/state/federal assistance
If you selected "No" above, please upload proof of any state benefits you may receive.

IE: EBT card, unemployment, FANF, etc
Cancelof
Our clinics require pre-payment in full. You will be invoiced for the balance due once your application is approved. Due date is 2 weeks prior to your scheduled clinic date. If pre-payment is not submitted before the due date, your clinic spot will be filled by someone else.*

Yes, I agree
By submitting this application, I agree that the deposit is non-refundable, my dog's breed is not on the restricted list and that my dog is not currently or will be over 55 pounds. I further agree to continue to monitor my dog's weight, if he/she is close to the weight limit.*

Yes, I agree
Signature of Owner or Animal Agent*

Clear
Application date

MonthDayYear
Date
Spay/Neuter Clinic deposit*
prevnext( X )
Spay/neuter clinic depositNon-refundable deposit towards the total cost of the spay or neuter of your dog(s); ONE FEE PER DOG. You will be contacted with the final amount and appointment date. All payments are processed through PayPal. You may pay using an existing PayPal account, or any major credit card / debit card.
$30 # of dogs

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

PMSPCA Spay/Neuter Clinic Application - Dog