Low Cost Clinic Application

Please fill out all the questions below to the best of your knowledge.

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email

(This may be needed to email vaccine records/register microchips if you choose the add on service)

We are a 100% volunteer run organization, calling is not an option for us most days, can we please text you? (You can opt out of SMS communications at any time)*

YesNoNo, please email me.

Please list your pets information below. Don’t forget to click ‘Save / Add ’ even if you don't have multiple pets coming to the clinic. We will need your dog's weight even if you do not know the breed.*

Does your pet(s) have any medical history or anything the vet should be made aware of before surgery?*

Does your pet have a bite history? If yes, explain. *

Do you have a cage, carrier, trap or something safe and secure to bring your cat(s) in? If you are applying for a dog, you wont need to bring a carrier you just need a collar and leash.*

YesNo I will need to borrow something.Yes, but not enough for each cat.My pet is a dog, I will have a collar and leash.

Which drop-off time & day works best for you? Morning of or clinic drop-offs are the only option for dogs.*

Leitchfield - Night before between 4:30-5:30pmLeitchfield - Morning of surgery between 6:00-6:30amBetween 5:30-6:00am at the clinic in Morgantown

Please check any option you'd like to add on below. Pricing is per pet. Leave blank if you do not wish to purchase any add-on services.

$5.00 Combo Vaccine + Rabies$2.00 Oral De-Wormer Capsules for Dogs & Cats$3.50 Oral Flea Medication Capsule (does not kill ticks)$10.00 Microchip$8.00 Topical combo medication -Fleas/De-Wormer/Ear Mites (Dogs must be heart worm negative, must have proof within last 5 months from a vet)$10.00 Extra pain medication

By submitting this application, I understand that a non-refundable prepayment will be due after my application is processed in order to guarantee my pet(s) spay/neuter spot, any add-on service payments will be due at the time of drop off.*

I understand.

I also understand that the risk of injury or death, although extremely low, is always present just as it is for humans who undergo surgery. I will be responsible for signing a liability waiver once my pet has been scheduled for surgery.*

I understand.