Order Number Date * First Name * Last Name * Street Address * Address Line 2 City * Postal Code Phone * Alternate Contact Number * Province * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Email * How did you hear about our Spay & Neuter Services? Have you applied to us before? * Yes No First Animal Information * Cat Dog Gender * Male Female I don't know Age * In years Colour/Description Second Animal Information Cat Dog Gender Male Female I don't know Age In years Colour/description Is your animal(s) on any medications? * yes no If yes, please list medications and reasons for taking them... Is your pet showing any of these symptoms: vomiting, rash or diarrhea? * Yes No How did you get your pet? * Stray Breeder kijiji Rescue Group Other Do you currently have a vet? * Yes No If yes, what is the name of your Vet Clinic? Is this a TNR? (if yes, please note there are additional fees and outpatient instructions for TNR services) * Yes No See for more information on what TNR means visit: http://spcans.ca/spca-vet-services/trap-neuter-return/ Are you on Public Assistance? * Yes No Do you receive Disability or Unemployment? * Yes No How many adults live in this household? * 18 years or older How many children live in this household? * under 18 years old Please list the TOTAL annual income of your household * Total combined income in $ Consent - 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. 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. *
