Owners Name *

First Name

Last Name

Mailing Address (If different from Physical Street Address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Phone *

(###)

###

####

Are you able to receive and print an Approval File online? *

Yes

No

Do you prefer to receive a mailed copy of the approval? *

Yes

No

Type of animal *

Dog

Cat

Pet's Sex *

Male

Female

Is your pet's rabies vaccination current? *

Yes

No

Both my pet and I are residents of Duplin County. *

Yes

No

I will allow up to four weeks to receive the Surgery Approval and I will not schedule the procedure until I have a printed copy of it in my possession. *

Yes

No

I will sign the Surgery Approval prior to the procedure. *

Yes

No

I understand that the Low Cost Spay/Neuter Program is limited to dogs and cats only. *

Yes

No

I understand that the reduced cost is for a routine spay/neuter surgery only. There may be additional costs which is my responsibility to negotiate with the vet. *

Yes

No

I understand that a current rabies vaccination is required. If my pet does not have a current rabies vaccination, I will pay an additional cost for the vaccination on the day of the procedure. *

Yes

No

I understand that each Vet has different requirements so I will check with my Vet before selecting the Vet, e.g. a money deposit or new patient fee. *

Yes

No

I understand that I can only have one pet spay/neuter surgery for this request. *

Yes

No

I understand that the Spay/Neuter Program is for pets of owners who have a financial need *

Yes

No