Spay or Neuter Assistance Request

REQUEST FOR SPAY OR NEUTER ASSISTANCE FOR
CHAMPAIGN COUNTY (AND NEIGHBORING COUNTIES), ILLINOIS

Answer every question completely.

What type of animals need to be sterilized:

Friendly Cat(s)
Wild/Feral Cat(s) [If humane trap is needed, please indicate below.]
Dog(s)
Both cat(s) and dog(s)
For each animal, please provide type (cat or dog), sex (male or female), and age. If there are any health problems or if the animal is in heat or possibly pregnant, please indicate that as well. Example: 1. Dog, Female, 2 years, In Heat 2. Cat, Male, 6 mos
Please provide the following contact information:

Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Home or Cell Phone

E-mail

AGREEMENT / COMPLETION: I have been told and understand that:

I am required to follow all pre and post-operative instructions from CATsNAP volunteers and/or veterinarian
All surgeries carry a risk due to anesthesia
No pre-operative bloodwork and/or tests are provided by CATsNAP unless I explicitly request it below and pre-pay the actual cost of the test or bloodwork
These services are for financially disadvantaged people who cannot afford to otherwise have their pet spayed or neutered.

I further understand that I am expected to make a donation to help cover some of the costs of surgery. Suggested minimum donation for tame felines are $20 (male) and $25 (female). The suggested donation for feral cats (male or female) is $10, and the animal will be eartipped. The suggested minimum donation for canines are $50 (male) and $65 (female). Surgery price includes a basic distemper combo vaccine. Other vaccines, such as rabies and feline leukemia, or specialized tests, like Feline FeLV/FIV or Canine Heartworm, as well as pre-operative bloodwork, are available for additional charges [see consent form]. I have also printed the attached

consent form and

post-surgery care sheet.

CATsNAP does not and cannot warrant the future health of this animal and is not responsible for an owner's failure to follow pre- or post-surgical directions. Should any post-surgery issues or condition come to the attention of the owner within 7 days of the surgery, CATsNAP must be notified immediately. If any problem should arise, CATsNAP can provide follow-up care under the following conditions: (a) CATsNAP is notified prior to any third party veterinary care, (b) CATsNAP deems that the problem is not a result of owner failure to follow pre- and post-operative instructions and is a direct result of the spay/neuter surgery, and (c) CATsNAP designates and schedules the exam. CATsNAP will not be responsible for any other charges.

In the event that you are unable to make the suggested donation, if you are requesting optional tests or services, or if you have a large group of animals needing help, please indicate circumstances below:

*ELECTRONIC SIGNATURE: By typing your name below, you are electronically signing this agreement and certifying all information.

PLEASE ALLOW 72 HOURS FOR RESPONSE

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home or Cell Phone
E-mail

Copyright © 2005 [CATsNAP]. All rights reserved. Revised: 01/02/07

Copyright © 2005 [CATsNAP]. All rights reserved.
Revised: 01/02/07