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Personal Information

* First name

* Last name

* Email

* Email confirmation

Home phone

Cell number

* Current Address

Current Address 2

* Zip

* City

Country

*State/Province

Household Information

Please indicate your annual household income from all sources.

less than $20,000/year$20,000 to $40,000/year$40,000 to $60,000/year$60,000 to $80,000/year$80,000 to $100,000/yearMore than $100,000/year

County of residence

Any additional details you would like us to know?

Pet Information

If requesting services for multiple pets, please provide information on each pet separated by a comma for the entire application.

Pet Name (if multiple pets separate names with a comma)

Species

Feline (Cat)Canine (Dog)

Gender

MaleFemale

Describe Primary Breed, Color and Coat Length.

Age of Pet and date of birth, if known, or estimate of current age

Approximate weight of pet in pounds.

Is Pet up to date on vaccinations?

Yes, up to date on distemper and rabies vaccineNo, not up to date on distemper and/or rabies vaccine

Please provide any history of medical problems.

Spay and neuter are considered major surgery and your pet will be under anesthesia. Please describe any medical conditions that may impact the outcome of this procedure. For example, is your pet in heat, pregnant, heartworm positive, sneezing, vomiting, diarrhea or unhealthy in any way? If your pet is healthy, please indicate that also.

Is your pet currently taking any medications? If so, please list names, dose and frequency.

For dogs only, are they currently on heartworm preventative?

YesNo

If female, please provide information on when they were last in heat, pregnant or nursing. If nursing age of litter? If pregnant, how far along?

Please describe how your pet gets along with people and other pets?

If cat, do you have a cat carrier to transport pet safely?

YesNo

If seen by a vet, please provide name and phone number of vet.

Acknowledgement

I hereby certify that the animals which will be sterilized are either owned by the applicant or strays with no known owners. All information provided above is truthful and correct to the best of my knowledge. Additionally, I understand that the Louisa Humane Society will not be held liable for any additional charges related to the sterilization procedure above the value of the voucher. I accept that I am responsible for all additional fees charged by the veterinarian. I acknowledge that vouchers will not be replaced, reissued or extended beyond the original date of expiration. Furthermore, I understand and agree that any veterinary service, including the sterilization procedure, is taken with all the standard risks associated with a surgical or veterinary treatment. I agree that the Lousia Humane Society, or any of its volunteers or contractors, will not be held liable for any complications due to surgery or treatment, including but not limited to death, injury or illness.

Acknowledgement

I agree with the above statements.I DO NOT agree with the above statements

I have read and agree to the terms and conditions. By checking this box I am confirming that I am 13 years of age or older.

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Public Spay Neuter Program

Personal Information

Household Information

Pet Information

Acknowledgement