Petrie Grant Spay/Neuter Appointment Request Form

Thank you for your interest in an appointment at the Sandhills Spay Neuter Veterinary Clinic (SNVC), located at 5071 US Hwy 1 N, Vass NC 28394! This application is for grant funding available for those that live OUTSIDE of MOORE County and receive financial assistance.

Please fill out the information below ONLY IF YOU ARE ON FINANCIAL ASSISTANCE SUCH AS MEDICAID OR FOOD STAMPS. IF you are NOT on financial assistance, please go back to our website and choose the general "Appointment Request Form". You may request the day of the week you would prefer your appointment on. We will attempt to meet your request to the best of our ability. In order to submit an appointment request online, we require a $50.00 appointment deposit. There is a $2.00 processing fee for all online and credit card transactions. PLEASE NOTE: WE ARE SCHEDULING 3-4 WEEKS OUT FOR ALL FEMALE APPOINTMENTS AT THIS TIME. Once we receive your appointment request and deposit, we will email you with our first available appointment. Please allow up to 48 hours (During normal business hours, Monday-Thursday) for our response. PLEASE COMPLETE ONE FORM PER PATIENT, PER APPOINTMENT NEEDED.
Petrie Grant - Financial Assistance Appointment Request Form

Sandhills Spay Neuter Veterinary Clinic - SNVC
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What County do you live in? *
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How do you prefer receiving your Pet's Records after surgery?*
Do you currently receive any type of government financial assistance?*

YesNo
Please provide a picture of your assistance below. If you receive EBT or WIC, you must provide your UP TO DATE eligibility letter. Financial Assistance must be up to date at the time of your appointment. WE CANNOT ACCEPT ONLY A PICTURE OF YOUR EBT or WIC CARD. We must see the current dates for eligibility. If you are applying with Medicaid, make sure that your card shows a current date (prior to one year from the issue or effective date listed).*

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Patients Name *
Do you have a Female/Male/Cat or Dog*

FEMALE CatMALE CATFEMALE DOGMALE DOG
Patients Color and Breed*
*** PLEASE NOTE THAT SOME BREEDS MAY REQUIRE A SURGICAL WAIVER TO BE SIGNED. ***
Patients Approximate Weight*
Patients Approximate Age (weeks, months, or years)*
You can now take a photo or upload a photo of you pet for their medical record!
Patient Photo Upload

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If you have a cat, are they INDOOR, OUTDOOR, BOTH, or FERAL ( feral means we can not handle the patient. Feral cats are required to come in a trap for appointments)
If your Pet is a FEMALE, has she ever had a litter of puppies or kittens?

YesNo
Date of last litter of puppies or kittens if applicable (** All females must be at least 14 weeks postpartum for surgery**)

MonthDayYear
Date
If your Pet is a FEMALE, is there a possibility that she may be pregnant at the time of her spay?*

No, my Pet is a MALENo, my FEMALE is NOT pregnantYes, my FEMALE IS pregnant (please note there is a $60.00 canine pregnancy fee and a $20.00 feline pregnancy fee in addition to surgery costs)Unsure (please note there is a $60.00 canine pregnancy fee and a $20.00 feline pregnancy fee in addition to surgery costs)
Are you requesting an appointment for more than one Pet? If you answer yes, please complete a new form per pet.*

YesNo
Preferred day of the week*

First AvailableMondayTuesdayWednesdayThursday
Will your Pet need a Rabies vaccine for an additional $15.00 or will you provide proof of a current Rabies vaccination? Please note, all patients are required to either provide a current Rabies certificate PRIOR to surgery, by check in for your appointment, or receive a Rabies vaccine at the time of surgery.*

Yes, my Pet will need a Rabies vaccine at the time of surgery for an additional $15.00 feeNo, I will provide a current Rabies certificate for my Pet at Check-in, PRIOR to surgery
Please provide a copy of your Pets current Rabies Certificate if available

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*** IF YOUR PET IS CURRENT ON HIS/HER RABIES VACCINE, A CERTIFICATE MUST BE PROVIDED PRIOR TO YOUR APPOINTMENT OR AT CHECK IN THE MORNING OF SURGERY. IF YOU ARE NOT ABLE TO PROVIDE PROOF OF A CURRENT RABIES VACCINE AT THOSE TIMES, WE WILL ADMINISTER A RABIES VACCINE AT THE TIME OF SURGERY. ***
Please check which additional services you would like at the time of your Pets surgery appointment

Nail Trim ($10.00)Ear Cleaning ($20.00)ProVecta - Flea/Tick prevention ($25.00-$30.00 for a 4month supply)Bravecto-Flea/Tick Prevention ($60.00 for a 3 month supply)Microchip and registrations($30.00)Canine DHPP vaccine ($10.00)Canine Bordetella ($10.00)Canine Heartworm Test ($20.00)Iverhart Max (Canine) heartworm prevention SINGLE month dose ($12.00)Iverhart Max (Canine)-heartworm prevention 6 month supply ($55.00)Feline FVRCP vaccine ($10.00)Feline leukemia vaccine ($10.00)Feline leukemia and FIV test ($25.00)Capstar tablet - immediate flea infestation treatment ($15.00)Canine post-operative mild sedation for at home recovery $15.00-$20.00 (price is based on patient weight) - Patients 6 months and olderUpgraded elizabethan collar (soft rim, secure velcro) $15.00-$20.00 (based on size of pet)
**If approved, this grant covers the cost of surgery including a pre-surgical exam, take home medication for post op recovery and an elizabethan collar**

**MALE felines DO NOT receive an elizabethan collar**

**If antibiotics or other medications are needed/recommended, they are not included in your pets surgery cost**
By signing below, you awknowlege that you understand that all pricing listed in this form is based on current and approved financial assistance. If your assistance is denied, those prices are not valid and you will be responsible for full payment of surgery and/or services. You also understand that the deposit to schedule this appointment is NOT the complete cost of surgery and the remaining balance with be due the morning of surgery at check in.
Signature*

Clear
Do you have any additional information on your Pet to provide?
*** Sugery is at the discretion of our veterinarians. Surgical waivers may be required based on the physical exam of your Pet, breed, age, and/or condition.***

*** Feral cats can ONLY be brought to their appointment in a live trap ***

*** Female patients MUST BE at least 14 weeks postpartum for surgery ***
** If you cancel or reschedule your appointment with less than a seven (7) day notice, the deposit to schedule a new appointment is $50.00. If you no-show for your scheduled appointment, the deposit to schedule a new appointment is $50.00.**

My Products*

Appointment Deposit (Required) Product Image

Appointment Deposit (Required)Includes $2.00 merchant fee

$52.00 Quantity

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

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