Yarmouth SPCA Dyke Family Animal Clinic – Low Cost Spay/Neuter Application form

Url

First Name *

Last Name *

Street Address *

Address Line 2

City *

Postal Code

Phone *

Alternate Contact Number *

Province *

Email *

How did you hear about our Spay & Neuter Services?

Animal Name(s)

Animal Information *

Cat

Dog

Both (Cat and Dog)

CATS ONLY- Do you have a cat carrier to transport your cat?

Yes

No - Will need to borrow one from the SPCA

No - but I will borrow one from a family member or freind

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

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 $

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 -

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. *

Consent - 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.

By 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. *