Appointment Request
Please complete the following form to request an appointment for our Free Dog Spay & Neuter Day on Tuesday, July 7th.
Owner Information
Your Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Pet Information
Do you have a dog or a cat?
*
Dog
Cat
Pet's Name
*
Age of pet
*
Sex
*
Male
Female
Breed/Breed Mix
*
Approximate Weight
*
In LBS
Is your pet current on vaccinations?
*
Yes
No
Unsure
Has your pet had any previous surgeries?
*
Yes
No
If yes, please describe.
Any known medical conditions?
*
Yes
No
If yes, please describe.
Is your pet microchipped?
*
Yes
No
Unsure
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Eligibility Information
Household Income Range
*
Less than $30,000
$30,000-$58,999
$59,000-$87,999
Number of people in household
*
Are you currently participating in any assistance programs?
*
SNAP, Medicaid, WIC, etc.
Reason for requesting free spay/neuter services
*
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Consent & Acknowledgements
Please read and initial each item:
I understand that submitting this form does not guarantee an appointment
*
I understand that my dog must be healthy at the time of surgery
*
I agree to follow all pre‑surgery and post‑surgery instructions
*
Submit
Should be Empty: