Prairieland Animal Welfare Center

1855 Windish Drive, Galesburg, IL 61401

(309)342-1275; fax (309)342-1276

PAWC thanks you for your interest in spaying / neutering your pet

Please read carefully and answer all the questions. Please PRINT.

The PAWC Office Personnel will review the following information.

You will be contacted as soon as possible regarding your qualification for spay/neuter assistance.

Last Name____________________________________ First Name ______________________________________

Phone ________________________ ADDRESS _____________________________________________________

CITY__________________________ ZIPCODE_________________ Driver License #____________________

How many people live in your home? Adults__________ Children____________________

Are you employed? o Yes o No o Part Time o Full time oother _________________

If Employed where? ___________________________________________________

Is anyone else in the household employed? o Yes o No o Part Time o Full time oother _________

If Employed where? ___________________________________________________

What is your monthly household income? ______________________ (You are required to show proof).

Are you on any government subsidy? o Yes o No (You are required to show proof).

If yes which program are you on? ________________________________________________________________

If no can you otherwise prove your eligibility for low-cost assistance? _________________________________________________________________________________________________________________________

How many animals live in your home? _____________

Which of these pets would you like spayed/neutered?

Pet 1: Name_____________________ Cat or Dog Breed: ____________________ Male Female? Age _______

Pet 2: Name_____________________ Cat or Dog Breed: ____________________ Male Female? Age _______

Pet 3 Name_____________________ Cat or Dog Breed: ____________________ Male Female? Age _______

Who is your veterinarian? ____________________________

Is your pet current? o Yes o No You will need proof of vaccinations. (If your pet is current on their vaccinations no extra fee will be charged).

I certify that all the above information is correct. Name ______________________________ Date__________

Sign

Accepted forms of proof for qualification WIC, Link, Medicaid, SSI, Unemployment, Active military or 2 consecutive pay stubs.

Your pet will be undergoing general anesthesia plus a surgical procedure today.

In order to recognize any underlying abnormalities your pet may have, we recommend having a pre-surgical blood profile run on your animal.

This consists of a CBC, which will check blood cells, and an ALT, ALKP, CREA, GLU, TP, and BUN, which will check blood glucose, kidney and liver enzymes.

These blood tests will help us assess the health status of your pet more completely and determine if there are any additional precautions,

we need to take before surgery. We highly recommend a blood profile for senior animals (animals older than 7 years).

There is an additional charge for these blood tests. We hope you understand the need for these important tests.

I DO_____ DO NOT _____ wish to have the pre-surgical blood work run.

If you want the pre-surgical blood work done please contact Galesburg Animal Hospital 343-9226

for an appointment as soon as possible.

________________________________________

Signature of pet owner or authorized agent