Dartmouth SPCA - HRM SPCA Animal Hospital Spay/Neuter Application Form

Name

Date *

First Name *

Last Name *

Street Address *

Address Line 2

City *

Postal Code

I am located in the following municipality: *

Phone *

Alternate Contact Number *

Province *

Email *

How did you hear about our Spay & Neuter Services?

Have you applied to us before?

Yes

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

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

Colour/Description

Is your animal(s) on any medications? *

If yes, please list medications and reasons for taking them...

Is your pet showing any of these symptoms: vomiting, rash or diarrhea? *

How did you get your pet? *

Stray

Breeder

kijiji

Rescue Group

Other

Do you currently have a vet? *

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) *

See for more information on what TNR means visit: http://spcans.ca/spca-vet-services/trap-neuter-return/

Are you on Public Assistance? *

Do you receive Disability or Unemployment? *

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. *

reCAPTCHA *

Dartmouth SPCA – HRM SPCA Animal Hospital Spay/Neuter Application Form