Name First Name * Last Name * Street Address * Address Line 2 City * Postal Code I am located in the following municipality: * Halifax/Dartmouth and surrounding region Hants County Queens County Lunenburg County Other Kings/Annapolis County Colchester County 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 Services? Have you applied to us before? Yes No Animal Name * First Animal Information * Cat Dog DOGS ONLY - Weight Range 0- 45lbs 50 - 100lbs 100 + lbs Please 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 * Male Female I don't know Breed (if known) Approximate Age * In years Colour/Description * Second Animal Name Second Animal Information Cat Dog Gender Male Female I don't know Approximate Age In years Breed if known 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? 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. * Would you like to apply for low income family subsidies? * Yes No If yes, you will be asked to provide income information to assess your eligibility 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 $ Would you like to Upload a picture showing your income now ? Yes No - I will email it later to vet@spcans.ca or I need time to look for it first!
