Spay/Neuter Form Richardson Rescue 803-684-6865
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First Name
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Last Name
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Street Address
Address Line 2
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City
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State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
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Indiana
Iowa
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Maryland
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
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Zip Code
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Phone Number
Email Address
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Where did you hear about our rescue group?
Internet
Brocure/flyer
Spay USA
Friend/relative
Other rescue group
Newspaper article
Telephone book
Radio
Petfinder.com
Television
Animal control
Billboard sign
RichardsonRescue.org
Vet's office
980-dogs
other
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How many incomes in the family?
One
Two
Three
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Are you recieving one of the following?
Unemployment
Social Security
Disability
Public Assitance
College student
Other reason for low cost program
Presently working
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Occupations of everyone in the home.
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Total household Income
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The above income is based on one of the following:
Weekly
Bi-Weekly
Monthly
Yearly
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Names and discription of animals to be treated. Please indicate sex, age and size.
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Are your animals vaccinations current?
Yes
No
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Name and number of current Vet
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Date of Rabies shot
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Date of DHLPP (Dog)
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Date of FeLv/Fiv (Cat)
If these shots are not up to date that will need to be given the day of surgery at an extra charge.
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Are any of these animals feral or aggressive?
Yes
No
Unknown
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If Yes please explain.
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I understand that during the performance of my pets spay/neuter there are risks involved when using anesthetics and or other medications and complications can occur not excluding death. Richardson Animal Rescue and all Veterinarians will not be responsible for any complications.
Yes
No
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Indicates Response Required
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