Spay/Neuter Request Form

DATE OF REQUEST

MonthDayYear

Full Name*

First NameLast Name

Relationship to Dog:

FosterAdopterOwnerHomeless Encampment

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

Pet Name*

Birthdate*

MonthDayYear

Sex*

Breed

Color of Pet

Color

Weight - YOUR DOG'S WEIGHT MAYNOT EXCEED 75# AT TIME OF SURGERY*

lbs

Surgery Requested*

Services Requested - Payment Due when registering for Spay/Neuter*

I am registering my DOG at this time for spay/neuter.

As the owner, I understand I am responsible for all costs associated with the selected surgery. I will make payment directly to PAW PAWS PET RESCUE/CORBINS CORNER COMMUNITY PET PANTRY acting as the agent for services being requested from SEAGLASS SPAY NEUTER CLINIC - JACKSONVILLE, FLORIDA who will be providing and performing the services requested.

I agree to supply a rabies certificate PRIOR to date of surgery. If one cannot be provided, I agree to have a rabies vaccine provided by SEAGLASS SPAY NEUTER CLINIC at time of surgery and will pay the $22.00 cost for said vaccine, which will include the proof of rabies certificate.

I UNDERSTAND MY DEPOSIT/CO-PAY IS NOT REFUNDABLE IF MY PET IS A NO SHOW AND/OR IF I NEED TO RESCHEDULE MY SURGERY DATE.

I UNDERSTAND I WILL RECEIVE AN INVOICE ONCE I AM ASSIGNED A DATE PREFERRED & CONFIRMED. INVOICE MUST BE PAID WITHIN 7 DAYS OF RECEIPT OR I WILL FORFEIT MY ASSIGNED TIME AND DATE.

SURGERY WILL BE PERFORMED BY SEAGLASS SPAY NEUTER CLINIC LOCATED AT 2893 EDISON AVENUE, JACKSONVILLE, FL 32254

UNLESS OTHERWISE ARRANGED, TRANSPORT TO SEAGLASS AND PICK UP FROM SEAGLASS IS MY SOLE RESPONSIBILITY.

Signature*

Spay/Neuter Request

Complete Pet information