Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address (if different from physical street address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

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

Yes

No

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

Yes

No

Type of Animal

Dog

Cat

Pet Sex

Male

Female

Is your pet's rabies vaccination current? *

Yes

No

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

True

False

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 addition costs 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