Spay Neuter Coupon – Fill Out and Use This PDF

SPAY NEUTER COUPON -- PLEASE PRINT OR TYPE --

SPAY NEUTER ASSISTANCE PROGRAM, INC.

P.O. BOX 126702

HARRISBURG, PA 17112-6702

(717)732-LESS (5377) www.snapofpa.org

Serving South Central Pennsylvania

SECTION 1 OWNER & ANIMAL INFORMATION ** ONLY ONE ANIMAL PER FORM **

Owner's Name

Street

I (we) hereby agree(s) to at all times release and hold harmless Spay Neuter Assistance Program, Inc., its oficers, directors, members, agents and assigns from and against any and all claims, liabilities, losses,

damages, charges, fees and expenses of every nature and character which I (we) may sustain or incur by reason or on account of the spaying or neutering of my (our) animal(s) described above. I (we) understand that the Spay Neuter Assistance Program's only involvement and purpose is to provide funds (with or without contributions from animal owners) for the spaying and neutering of domestic animals. Accordingly, I (we) hereby issue this release from liability. I (we) further agree to execute whatever documents are required by the Doctor(s) of Veterinary Medicine who are to perform the spaying and neutering on my (our) pet.

DateSignature

(Must be at least 18 years of age)

Instructions:

1. Complete Section 1 including signature and date.

2.Select a veterinary practice from the list on back and call THEM to schedule your appointment.

3.Specify that you are using a Spay Neuter Assistance Program Coupon.

4.This coupon as well as all certiicates for required vaccinations must be presented at the time your pet is admitted to the veterinary practice for surgery.

5. The entire cost for surgery is due at the time of service.

The Veterinary Practices listed on the back of this form participate in SNAP's low-cost

program and honor the SURGERY rates shown below.

ADDITIONAL CHARGES MAY BE IMPOSED AT THE DISCRETION OF EACH PRACTICE

LOW COST SPAY NEUTER PROGRAM PARTNER

Humane Society of Harrisburg Area

The participating veterinary practices listed below establish their own guidelines for acceptance of SNAP

Spay Neuter Coupons & Grants. A preliminary ofice visit, proof of current vaccinations, blood work, overnight stay, and/or additional vaccinations/shots, may be required. Fees for surgical complications, females in heat or pregnant, or males with undescended testicles may also be applied. These and any other

costs will be charged at the Veterinarians’ discretion, at their rates, and are in addition to the surgery price indicated on this form. Any and all of these ancillary charges are your inancial responsibility.

It is recommended that you obtain an estimate of costs and understand all conditions, prices, and requirements prior to selecting a practice and scheduling your pet for surgery.

In some cases, a deposit is mandatory to secure your appointment.

Age restrictions vary by practice.

When calling to schedule your pet for surgery, identify yourself as a SNAP Client. Failure to do so will result in standard ofice rates being charged.

The low cost for Spaying / Neutering your pet is made possible thanks to the donation of time and supply costs by our participating veterinarians.

Please show your appreciation for the important community service they provide

by keeping your appointment.

THIS COUPON HAS NO MONETARY VALUE.

It will only guarantee the reduced cost spay neuter surgery prices as shown

at the participating veterinarians listed above.

Cats and dogs should be a minimum of 4-5 months of age and younger than 7 years and must be up-to-date on vaccinations. Proof of current vaccinations (rabies and distemper combination) must be provided. If proof of vaccination is not provided, vaccines will be administered by HSHA for an additional $10 each.

SECTION 2 FOR SNAP VETERINARIAN USE ONLY

The animal described above on

had the following Veterinary procedure performed Fee $

(Veterinary Hospital)

(Signature of Veterinarian)

SECTION 3 FOR SNAP USE ONLY

Grant #

Date Approved

Amount from Client

Amount from SNAP

Total

PLEASE READ BOTH

PLEASE READ BOTH

SNC 05/13 SIDES CAREFULLY

SIDES CAREFULLY

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