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DAH Low Cost Spay & Neuter Clinic
Feline Registration Form
25
Questions
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1
Your Name
*
This field is required.
Please enter your FIRST and LAST name. This is the name of the OWNER of the pet being registered, and must match the name on the eligibility documentation.
First Name
Last Name
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2
Address
*
This field is required.
Please enter a valid address.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
Phone Number
*
This field is required.
Please enter a valid phone number.
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4
Can we send text messages to the provided phone number?
*
This field is required.
If you select yes, you will receive text message reminders for due dates and appointment instructions. Otherwise, they will be sent via email.
Yes
No
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5
Email
*
This field is required.
Please enter a valid email. Updates on your application and appointment will be sent to you via email.
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6
Pet Name
*
This field is required.
Please register ONE pet at a time.
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7
Breed
*
This field is required.
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8
Color
*
This field is required.
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9
Pet Date of Birth
*
This field is required.
If unknown, please provide an estimate.
-
Month
Day
Year
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10
Pet Weight in Pounds
*
This field is required.
If unknown, please provide an estimate or range.
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11
Sex
*
This field is required.
Male
Female
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12
Package Selection
*
This field is required.
Please select a package. Please note that this form is for CATS ONLY. If you are not registering a cat, please go back and select the appropriate form. Includes pre-surgical exam, spay or neuter procedure, tattoo, and pain medication to go home.
$70 Feline neuter (MALE)
$90 Feline spay (FEMALE)
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13
Vaccine Services
*
This field is required.
Select all that apply. Please note that if you are unable to provide proof of current vaccinations, you will be required to have these updated at the time of service at an additional cost. If your pet is not up to date on the required vaccinations (Rabies and Feline Distemper/FVRCP), you must select one or more of the services below.
$50 Feline package: rabies vaccination with tag and certificate, distemper vaccination and intestinal parasite exam.
$20 Rabies vaccination (REQUIRED IF NOT UP TO DATE)
$20 Distemper vaccination (REQUIRED IF NOT UP TO DATE)
None - My pet is up to date on the required vaccinations and I have submitted proof to dahlowcostclinic@gmail.com
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14
Additional Services:
Optional additional services. If you do not wish to select any additional services, select "NEXT" below.
$12 Elizabethan collar (cone to prevent licking of incision site, HIGHLY recommended)
$40 Microchip implantation and registration
$25 Intestinal parasite exam
$45 Triple test, FIV/FELV/heartworm
$50 Additional charge for males with an undescended testicle
$50 Umbilical hernia repair
$0 Ear tip: This is a universal sign to the community that your cat has been spayed or neutered. Surgically removing a section of the ear allows your outdoor cat to be easily identified as spayed or neutered so they are not accidentally trapped for the procedure in the future.
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15
Total
This is the total amount due for your selected services. Once your application has been approved, you will receive a link to make a payment.
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16
Carrier Requirement
*
This field is required.
All cats MUST be dropped off in a carrier, preferably hard-sided. If bringing multiple cats, each MUST be in their own individual carrier. There will be NO exceptions to this.
I understand and agree.
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17
Payment
*
This field is required.
I understand that payment for my selected services will be due 2 weeks prior to my scheduled appointment.
I understand and agree.
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18
Eligibility
*
This field is required.
I understand that in order to qualify for the low cost spay & neuter clinic, I must meet the eligibility guidelines. I understand that my application cannot be processed until this information has been received. I understand that if I do not meet the eligibility guidelines, I cannot proceed with scheduling through the low cost spay & neuter clinic.
I understand and agree.
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19
Eligibility:
Please upload your eligibility verification here. Visit the FAQ page on our website to view the eligibility guidelines.
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20
Vaccinations
*
This field is required.
Rabies and Distemper vaccinations are required to be up to date for dogs and cats. Please e-mail proof of these vaccinations to dahlowcostclinic@gmail.com prior to making your appointment. If proof of vaccination cannot be provided these vaccinations will be done at the time of the spay or neuter at your cost. If you provide proof of a previous rabies vaccination, even if it is expired, the rabies vaccination and certificate that we give will be good for 3 years. Without proof of prior vaccination the certificate will be good for one year.
I understand and agree.
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21
Vaccinations:
Please upload your pet's vaccination records here IF APPLICABLE. If you have selected vaccination services with your pet's procedure, then you do not need to provide vaccine records and can select "NEXT". Remember: Rabies and Feline Distemper/FVRCP are BOTH required.
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: 10.6MB
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22
Symptoms
*
This field is required.
A pre-surgical exam will be performed prior to your pet's procedure. If the findings of this exam indicate that your pet may be at an increased risk of complications while undergoing anesthesia, the doctor may recommend OR require that you postpone your pet's procedure. Symptoms to look out for include: coughing, sneezing, vomiting, diarrhea, abnormal behaviors, etc. If you pet is displaying any of these symptoms prior to their scheduled surgery date, please let us know as soon as possible.
I understand and agree.
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23
Behavior
*
This field is required.
If your pet is aggressive towards humans or other animals then we may not be able to proceed with their procedure, for your pet's and our staff's safety. If this is case, your pet may be sent home with sedative medications and rescheduled to the next available date.
I understand and agree.
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24
I have read the following, understand what it says, and agree
*
This field is required.
I am the owner/authorized agent for the animal named above. I give permission for the procedure(s) named above. I understand that the doctors and staff of Davis Animal Hospital will use all reasonable precautions against injury, escape, or death of my pet. I understand that anesthesia and surgery always involve some risk to my pet (such as unknown internal physical abnormalities, medication allergies, surgical complications, internal bleeding, shock, incision dehiscence, and post-surgical infections) and agree to hold the hospital and its employees harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event complications arise and I cannot be immediately contacted at the above listed phone number(s), I request that the doctors and staff make the medical decision deemed best for my pet.
I understand and agree.
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25
Signature of Owner/Agent
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