FoR Quick Search

Spay/Neuter Form *** Eligibility is limited to residents of MD, DC, VA and WV! *** Each year, over 12 million animals are killed in our nation's shelters, because there are not enough homes for them. We thank you in advance for being part of the solution to the tragedy of pet overpopulation. Applicants will qualify for a $25 rebate. Call for your pre-approval at 443-535-9944 (Susan Wong's home phone number). If you provide additional evidence of financial need, you may also qualify for additional discounts up to $100.00. See details below. To receive your rebate, please fill out the form below. Name: Address:  Apartment or Suite: City: State: Please Select State DC MD VA Zip: Phone: Best Time to Reach You: (please specify a.m. or p.m.) Email Address: Please indicate the name, age, and sex of the rabbit(s) you would like spayed or neutered. Name Age Sex Male   Female   Unknown Male   Female   Unknown Male   Female   Unknown Male   Female   Unknown Male   Female   Unknown Does/do your rabbit(s) have any health problems, or previous reactions to anesthesia, etc?    Yes  (Please describe) No If yes, please describe: If you have one, please provide the name and phone number of your regular veterinarian. Name:      Phone Number:     FURTHER FINANCIAL ASSISTANCE:   You may also qualify for additional discounts. Please fill out the below form to determine if you qualify for more discounts. are single, not claimed as a dependent of another person or family, and your annual income is less than $25,000; are single with dependents, or married, and your total household annual income is less than $40,000. Please provide a copy of one of the following as proof of eligibility for further income assistance (Note: You may block out personal identifier such as social security numbers on these forms) : Last Year's Income Tax Form Free Lunch All W-2 Forms WIC Section 8 County Social Services Benefits VA Disability Food Stamps Social Security Disability AFDC POST SURGICAL PICK UP: All animals MUST be picked up at the time specified by the veterinarian's office when your pet is admitted. If you do not pick up your pet, additional boarding fees may be charged. In the event that the animal is not picked up, your animal will be considered abandoned and may be humanely destroyed or placed for adoption. Abandoning your pet does NOT relieve you of paying additional fees. I understand it is my responsibility to present my pet for follow-up visits related to the spay/neuter procedure if required by the veterinarian. For example, a second (typically, no cost) visit may be necessary to remove stitches. By checking this box, I certify I have read and understand the above two paragraphs.     AUTHORIZATION AND INDEMNIFICATION: I authorize House Rabbit Sanctuary, and all participating veterinarians, employees, and volunteers to receive, prescribe for, treat, or operate upon my pet animal(s) when presented per this agreement. I agree to indemnify, hold harmless and release House Rabbit Sanctuary, and all participating veterinarians, employees, and volunteers, from and against all action claims, damages, disabilities, or expenses, including attorney's fees and witness costs that may be asserted by any person or entity, including myself, arising out of or in connection with the care, treatment, surgery, or safe-keeping of the animal(s). Further, I understand that it is not possible for you to guarantee that any medical or surgical procedure will be successful and without complication. I certify I have read and understand the above two paragraphs: By checking this box, I certify I have read and understand the above paragraph. *** Eligibility is limited to residents of MD, DC, VA and WV! ***

© 2008 Friends of Rabbits & House Rabbit Sanctuary
P.O. Box 1112 | Alexandria, VA 22313 | Phone: 703-627-7892 | E-mail: info@friendsofrabbits.org