Spay It Forward Application
Welcome to the Southern Paws Inc. Spay It Forward low cost Spay/Neuter program!  We are so excited to be partnering with different veterinary practices around Bergen County, NJ to bring this program to life and to provide a lower cost option for those looking to spay or neuter their pet!  If you are interested in signing your dog up for our low cost voucher program, please fill out this form and one of our team members will be in touch with you shortly! Please sign each animal up separately.
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Email *
Last Name *
First Name *
Organization Name If Any
Was Your Dog Adopted From Southern Paws Inc.? *
If you adopted your dog from Southern Paws Inc. Please tell us their original name.
Which Service Are You Inquiring About? *
What type of pet are you inquiring about services for? *
Address *
Apartment/Unit #
City *
State *
Zip Code *
County *
Primary Phone Number. Please be sure to be available  the day of surgery should we need to get in touch with you. *
Emergency Contact Name (Secondary Person) *
Emergency Contact Phone Number (Secondary Person) *
Are You Receiving Any Form Of Financial Government Assistance At This Time? *
If Yes To The Previous Question Please Tell Us About The Type Of Financial Government Assistance You Are Receiving.
Have You Ever Participated In The Spay It Forward Program? *
How Did You Hear About Us? *
Name Of  Dog/Cat *
Sex Of  Dog/Cat *
Age Of  Dog/Cat (specify years or months) *
Breed Of  Dog/Cat *
Is Your  Dog/Cat A Pure Breed Or A Mix? *
Color Of Coat *
Approximate Weight Of Your  Dog/Cat *
Would You Like Your  Dog/Cat To Receive A Rabies Vaccination The Day Of Surgery? *
I Understand That My  Dog/Cat Will Receive A Mandatory Small Tattoo On Their Underside To Show They Have Been Sterilized. *
How Long Have You Known This  Dog/Cat? *
Within The Last Two Weeks Has Your  Dog/Cat Displayed Any Of The Following (Check All That Apply) *
Required
Within The Last Two Weeks Are You Aware Of Your  Dog/Cat Having Any Changes To The Following (Check All That Apply) *
Required
Are You Aware Of Your  Dog/Cat Having Any History Of The Following (Check All That Apply) *
Required
Has Your Dog/Cat Ever Had A Seizure? *
Does Your Dog/Cat Have Any Known Reactions To Drugs, Vaccinations or Medications? *
Please List Any Medication The Dog/Cat Has Taken In The Past Month (Including Supplements) *
Please Explain Any Questions Above That You Answered "Yes" Too.
I Understand That If My Dog/Cat Is Aggressive Or A Bite Risk In Anyway, I Will Be Required To Muzzle My Dog/Cat Prior To Check In. *
I Understand That I Must Arrive & Sign In at my designated clinic, Within 15 Minutes Of The Designated Time Of My Appointment, To Avoid A $50.00 Late Fee. *
Liability Release:

I agree that I am the owner/guardian of the dog/dogs registered above under the Southern Paws inc. Spay It Forward Program.

I understand that although the spay/neuter/dental surgery is performed under approved standards of practice in the veterinary profession, there is always a risk to any animal undergoing a medical procedure. Although your pet will be treated with the upmost quality of care, as with any medical procedure, complications or unexpected difficulties may arise during or after surgery.  
  
I understand that Southern Paws Inc. is solely responsible for providing the low-cost voucher and has no involvement in the veterinary care provided by the participating clinic.

I understand that Southern Paws Inc. is not responsible for the veterinary care provided by the clinic and disclaims any liability for any injuries, illnesses, or other adverse outcomes related to the procedure.

I understand that any follow-up questions or concerns regarding the spay or neuter procedure will be directed to the participating veterinary clinic. Southern Paws Inc. is not involved in post-procedure care.

I agree that I am of sound body and mind, and that I am a legal adult (at least 18 years of age).  I acknowledge that I have read and understand the full contents of this agreement, and agree to the terms in their entirety.

I acknowledge my digital signature and understand that I shall be bound by its' Terms and Conditions contained herewith.

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A copy of your responses will be emailed to the address you provided.
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