Yarmouth Animal Hospital Spay & Neuter Application Step 1 of 3 33% Please upload Proof of IncomeProof of income is required to qualify for the program. This can be a statement of assistance if you are on social assistance, or a Notice of Assessment from Revenue Canada. Please attach here, if you do not have a copy to attached you will need to provide a copy before we can book an appointment for your pet.CONTACT INFORMATIONDate Date Format: MM slash DD slash YYYY Pet Owners Name* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Contact Number*Alternate Contact NumberEmail How did you hear about our Animal Hospital? ANIMAL INFORMATIONAnimal Name (s)*Animal Information*CatDogBoth (Cat and Dog)CATS ONLY - Do you have a cat carrier to transport your cat?YesNo - Will need to borrow one from the SPCANo - but I will borrow one from a family member or freindWeight Range - FOR DOGS ONLY0- 45lbs50 - 100lbs100 + lbsPlease provide us with the approximate weight range of your dog, so we can ensure we assign an appropriate kennel size for your pets visit. Gender*MaleFemaleI don't knowApproximate Age?*in yearsColour/Description?Is your animal(s) on any medications?YesNoIf yes, please list medications and reasons for taking them...Is your pet showing any of these symptoms: vomitting, rash or diarrhea?*YesNoHow did you get your pet?* Stray Breeder Kijiji Rescue Group Other Do you currently have a Veternarian?*YesNoIf yes, what is the name of your Vet Clinic?Is this a TNR? (a feral, wild, outdoor cat)*YesNoSee for more information on what TNR means visit: spcans.ca/spca-vet-services/trap-neuter-return/ FINANCIAL INFORMATIONAre you on Public Assistance?*YesNoDo you receive Disability or Unemployment?*YesNoHow many adults live in this household?*18 years and olderHow many children live in this household? (under 18 years old)*Please list the TOTAL annual income of your household ($)*Total combined income in $$Please tell us how having your pet spayed/neutered would help you or change/improve your life and/or your pets life*This may factor into the selection process so please be detailed and describe how this will help both you and your pet.Do you currently have kittens/puppies you need help finding homes for?Do you currently care for or see feral/wild cats that are in need of spay/neuter help?Consent for use of information* YES By selecting YES and submitting this form you consent to the use of the information contained within in marketing or publication materials. Any information submitted will remain anonymous, your personal information will not be shared with anyone outside of the SPCA.CONSENT (click on text below to agree to the statement)* Yes - by submitting this form I hereby cerifty that the information i have provided is truthful and correct to the best of my knowledge. I hereby agree to waive any and all claims for damages against the Nova Scotia SPCA, and any officers, volunteers, or agents of the program in the event of death or injury to the animal during surgery. I also consent to the SPCA contacting me regarding this application.