Spay & Neuter Voucher Application

Name

Phone

Spouse Name

Spouse Phone

Address

City

State

Zip Code

Age

Name and ages of people living in household

How did you year about Lovebugs Rescue?

Do you own or rent

Rent

Own

Do you have a dog door?

Yes

Occupation

Employer

Hours per week

Spouse Occupation

Spouse Employer

Hours per week

Total annual household income

Unaltered Pet 3 Information

Name

Age

Type/Breed

Sex

Weight

Where did you get your pet?

Do you currently have a vet?

Yes

Vet contact

Please list any medical conditions your pet has

Please list any behavioral issues your pet may have (shy, bite history, leash reactive)

Have you had blood work done on your pet in the last year?

Yes

Does your pet have any known reactions to anesthesia?

Yes

DISCLAIMER PLEASE READ BEFORE SIGNING:

I am aware that if approved, Lovebugs Rescue uses a third party veterinarian for the procedure.

Lovebugs Rescue does not run pre-anesthesia blood work, which may provide information about any unknown health issues my pet may have. I have the option to have the vet run pre-anesthesia blood work that I will pay for.

I understand that there are risks to putting a pet under anesthesia and I will not hold Lovebug Rescue responsible if anything should happen to my pet as a result of the procedure.

I am financially responsible for a $25 co-pay to Lovebugs Rescue to secure my voucher.

I am financially responsible for any additional vet care that I request such as blood work, vaccines, flea prevention, dental work. This will be solely at my discretion between myself and the veterinarian providing services.

By signing/typing my name in the signature line below, I acknowledge that I have read the disclaimer and agree to these terms and conditions.

Name

Signature

Date