Spay/Neuter Clinic

Date

MonthDayYear
Date of this application
HHPR LOW-COST SPAY/NEUTER CLINIC

This clinic is sponsored by Halfway Home Pet Rescue, the Elmina B. Sewall Foundation, and the Maine Community Foundation. It will be held at 40 Broadway in Caribou, the old Broadway Electric building near Hogan Tire.

IF YOU HAVE MORE THAN 1 CAT TO BRING TO THIS CLINIC: Complete an application for EACH different cat. Bring each cat in its own CLEAN HARD carrier with a CLEAN towel, blanket or puppy pad.

If possible, we ask for a donation of $75 for females and/or $50 for males. We will fix your cat if you cannot afford a donation.
INCLUDES: Exam, Spay/Neuter, Distemper, Rabies. Microchips are available for an extra $40.

Total street value of $275 to $300 for the entire medical care.

If you have state benefits, you will need to bring/show proof.
Owner Name*

First NameLast Name
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Address*

Street Address

PO Box/Mailing Address if different from Street Address

CityState

Postal / Zip Code
Email*
example@example.com
PLEASE READ CAREFULLY: I do not hold Halfway Home Pet Rescue, Inc., the Veterinarians, Vet Techs, Shelter Workers/Volunteers responsible in case the cat has a Medical/Birth defect unknown to the Spay/Neuter Team. Please let the Team know if you are aware of any conditions. Enter your initials in the box below if you agree with this statement.
Your signature in the box below is your legally signed consent.*

Clear
Your initials in the box below is your signature consent.*
Cat's Name*
Cat's Age (Indicate Years)*
Example: 2 Years
Cat's Age (Indicate Months)*
Example: 4 Months
Cat's Gender*

MaleFemaleSex Unknown
Cat's Color*
example: orange tiger with white
Length of Hair*

ShorthairLonghairHairless
Any known medical or behavioral issues*
Briefly describe
How did you get your cat?*

StrayFriendRescueShelterPet StoreHoarder
Do you have any form of public assistance: food stamps, SSI, SSD, TANF, WIC*

Yes, I do have state benefitsNo, I do NOT have state benefits
If YES, this DOES NOT affect your application, but it does help HHPR pay the medical bill through the HelpFixME program.
Indicate type(s) of state assistance.*

Food stampsTANFWICSSISSDIncome below poverty level (Tax return is proof)N/A I don't have assistance
Which race or ethnicity best describes you? (Please choose only one.) This information allows us to comply with some of our funding source requirements.*

American Indian or Alaskan NativeAsian / Pacific IslanderBlack or African AmericanHispanicWhite / CaucasianMultiple ethnicityOther
What's the best way to contact you?*
Treatment at the clinic is for SPAY or NEUTER, DISTEMPER & RABIES VACCINATIONS, 30-DAY FLEA PREVENTION, NAIL TRIM, EAR CLEANING, TREATMENT FOR EAR MITES & WORMING (if needed). Estimate value $225. PLEASE DO NOT FEED YOUR PET AFTER MIDNIGHT THE NIGHT BEFORE SURGERY. THE CAT CAN HAVE WATER.
PLEASE BE SURE TO ACCURATELY ENTER YOUR ACTIVE PHONE NUMBERS and EMAIL. THIS IS HOW WE WILL REACH YOU WITH YOUR CLINIC APPOINTMENT DATE AND TIME.

When you submit this application, you should see a Thank You page. This is not the appointment. If you do not see that page, scroll up, you might need to enter the verification code again.

When the clinic schedule is made, we will CONTACT YOU.
Please verify that you are human*
Should be Empty: