Low Income Spay & Neuter Form | Gwaii Animal Helpline Society

This form was completed by:

Date Of Appointment (Appointment must be made by pet guardian)

Owner Name

Phone Number

Full Living Address (Include Village/City & Postal Code)

Full Mailing Address (Include Village/City & Postal Code)

Questions to determine eligibility: Are you any one of the following (check all that apply):

Unemployed

On disability

On income assistance

Single parent family

Underemployed (Casual or part-time only)

Suffering illness or medical issues

Limited pension not covering the rising cost of living

Any other hardships? Please explain:

Do you Agree to Sign a Waiver?

yes

Pet's Name

Pet's Age

Brief physical description of pet (eg. breed, colour, type of fur):

Dog or Cat?

dog

cat

Male or Female

male

female

Last Vet Visit?

Last treated for fleas?

Last treated for ear mites?

Needs a carrier?

yes

Do you have transportation?

yes

How much are you able to contribute?

Notes