Owner Name:

Phone:

Street address:

City:

State:

Zip:

Dog Name:

Age:

Gender:  

Male Female

Approx. Weight:

Breed (if known):

Is your dog current on rabies vaccination?

Yes No

(rabies vaccination is required by law before performing vet services)
*If pet is not current or owner can’t provide proof of vaccination, an additional $5 will be needed to cover part of vaccination cost.

Is he/she on heartworm preventative?

Yes No

*If your dog is not on heartworm preventative, he/she may have heartworm, a serious illness that weakens the heart and can place your dog at risk during surgery. By submitting this application, you give AWF and the veterinarian the right to conduct a blood test prior to surgery. If your dog tests positive for heartworm, the vet can refuse to conduct the spay/neuter.

Household yearly income:

Source of Income/Employer:

Do you receive public assistance? (Food stamps, Section 8 vouchers, etc.)

Yes No

*If yes, list:

Number of adults in household:

Number of children in household:

Other dogs/cats in household: 

# of Dogs         # of Cats

Neutered/Spayed?

Yes No

Which days work best for your pet’s neuter/spay? All surgeries are typically done early morning and pet can usually be picked up that afternoon. Pets can be dropped off at vet clinic the night before if needed.

Monday       Tuesday      
Wednesday       Thursday    
Friday

By clicking on submit, I certify that the information I have given is true. I understand that the Animal Welfare Foundation of Iowa reserves the right to deny my application for any reason. I further authorize the investigation of all statements in this application.

After submitting your pet's spay/neuter application and waiver online, please send a check or money order for $10 ($15 if your pet needs a rabies vaccination) to the address below. Please enclose a brief note that says "paperwork submitted online." Your application can't be processed until your check is received.

AWF
PO Box 573
Marion, IA 52302

Questions? Call (319) 462-5683