Name *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you qualify for government assistance? *

(This is not a disqualifier, but needed for end of grant reporting)

Yes

No

Are you active duty or a veteran of any military branch? *

(This is not a qualifier, but needed for end of grant reporting)

Yes

No

Is your pet a... *

Cat

Dog

Is your pet... *

Male

Female

Pet's Estimated Date of Birth *

MM

DD

YYYY

Is your pet... *

In heat (female)

Pregnant (female)

Undescended testicle(s) (male)

None of the above

Is your pet current on the following vaccines? *

Proof of current vaccines will be required. If your pet is not current, or proof cannot be established, your pet will receive age appropriate vaccines during the procedure.

FVRCP (cat)

DHLPP (dog)

Rabies

Not Current - No Proof

Do you have an established vet? *

Yes

No

Can you provide day of transportation to and from the vet? *

Yes

No

Would you be willing to use a different vet if it meant your pet could get in sooner? *

Yes

No

By submitting this application, I certify that: *

I am the rightful owner of the described dog or cat

*

I am seeking financial assistance from Clowder 9 Ranch to have my dog or cat spayed or neutered

*

I will be responsible for any charges for services above and beyond those negotiated with Clowder 9 Ranch (e.g. vaccines, parasite treatment, antibiotics, pain meds, etc.)

*

If I elect to use my established veterinarian, I am responsible for scheduling the appointment

*

Should I need to cancel or reschedule my appointment, I will provide a minimum of 48 hours notice to Clowder 9 Ranch and/or the veterinarian.

*

If I elect to use a Clowder 9 Ranch-associated veterinarian, Clowder 9 Ranch will schedule the appointment, and the use of said veterinarian will not warrant an "established patient" contract.