SPAY NEUTER COUPON - Download Now PDF by isv27825

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									                                 SPAY NEUTER COUPON                           -- PLEASE PRINT OR TYPE --
                                                                                                                Select the veterinarian of your choice from the list below:
                            SPAY NEUTER ASSISTANCE PROGRAM, INC.                                                      (Failure to inform the veterinary staff at the time you schedule surgery
                                          P.O. BOX 126702                                                             that you are using a Spay Neuter Coupon will result in standard office rates
                                     HARRISBURG, PA 17112-6702                                                        being charged.)
                                      (717) 732-LESS (5377)
                                   Serving South Central Pennsylvania                                           Each participating veterinary practice listed establishes their own guidelines for acceptance
                                                                                                                of SNAP coupons. Please contact each practice individually for particulars regarding
SECTION 1 OWNER & ANIMAL INFORMATION                     ** ONLY ONE ANIMAL PER FORM **
                                                                                                                additional fees and surgery restrictions.
           Owner's Name
                                                                                                                            CUMBERLAND COUNTY                                  DAUPHIN COUNTY
           Street
                                                                                                                         **Newville Animal Hospital                    **Colonial Park Animal Clinic
           City                                               State                Zip
                                                                                                                      Farrell Veterinary Associates, Inc.                   Harrisburg 540-7140
           Phone No. Daytime                                  Evening                                                          Newville 776-6311
                                                                                                                                  (Cats Only)                          **Noah's Ark Veterinary Center
        Cat Male                 Dog Male                     Pet's Name                                                                                                    Harrisburg 652-5923
            Female                   Female                                                                             **Holly Pike Animal Hospital
                                                              Pet's Age                                               Farrell Veterinary Associates, Inc.
                                                                                                                               Carlisle 240-0700
   I (we) hereby agree(s) to at all times release and hold harmless Spay Neuter Assistance Program, Inc.,                         (Cats Only)
its officers, 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               **Gettysburg Road Animal Hospital
reason or on account of the spaying or neutering of my (our) animal(s) described above. I (we) understand                  Mechanicsburg 697-7373                              LEBANON COUNTY
that the Spay Neuter Assistance Program's only involvement and purpose is to provide funds (with or without
                                                                                                                                                                          **Palmyra Animal Clinic
contributions from animal owners) for the spaying and neutering of domestic animals. Accordingly, I (we)                **Lower Allen Veterinary Clinic                       Palmyra 838-5451
hereby issue this release from liability. I (we) further agree to execute whatever documents are required by                 Camp Hill 975-9711
the Doctor(s) of Veterinary Medicine who are to perform the spaying and neutering on my (our) pet.                                                                           **Pet's Day Surgery
                                                                                                                         **Silver Springs Animal Clinic                       Lebanon 675-2080
Date                               Signature                                                                                Mechanicsburg 766-5980
                                                              (Must be at least 18 years of age)                                                                                  YORK COUNTY

                                                                                                                        **Willow Mill Veterinary Hosptial              **Hopewell Veterinary Service
                       FEE SCHEDULE - Client Responsibility                                                                 Mechanicsburg 766-7981                         Stewartstown 993-5141
                                           MALE            FEMALE
                      CATS                 $25.00            $40.00                                                        Boiling Springs Animal Hospital                     MOBILE CLINIC
                      DOGS 0 - 80 lbs. $55.00                $65.00                                                                 550 Park Drive
                      over 80 lbs. - Fee varies by veterinary practice.                                                      Boiling Springs, Pa. 17007
                                                                                                                                                                     Keystone Mobile Veterinary Services
                                                                                                                                                                                1-800-577-9738
                THE PRICES LISTED ABOVE ARE FOR SURGERY COSTS ONLY.                                                                717-258-4575                          (*$25.00 Per House Call Fee)
               (With undescended testicles in males, the fee varies by veterinary practice)                                                                        (Minimum of 9 animals required for service)


THIS COUPON HAS NO MONETARY VALUE. IT IS ONLY GOOD FOR THE REDUCED
       COST SPAY NEUTER PRICE AT PARTICIPATING VETERINARIANS
                                                                                                                **This facility requires a mandatory office visit charge in addition to the surgery fee if
                                                                                                                  this is your pet's first visit to this veterinary practice.
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.
                                                                                                                The low cost for Spaying / Neutering your pet is made possible thanks to the
   3. Specify that you are using a Spay Neuter Assistance Program Coupon.                                       donation of time and supply costs by our participating veterinarians. Please show
   4. This coupon as well as all certificates for required vaccinations must be presented at the time            your appreciation for the important community service they provide by keeping your
      your pet is admitted to the veterinary practice for surgery.
   5. The entire cost for surgery is due at the time of service.                                                appointment.
                                                                                                                SECTION 2 FOR SNAP VETERINARIAN USE ONLY                SECTION 3 FOR SNAP USE ONLY
Additional Information:                                                                                         The animal described above on                           Grant #
   1. Any office visit charges, examination fees, additional charges for surgical complications
      or females in heat or pregnant, required vaccination costs, or any veterinary services you                had the following Veterinary procedure performed        Date                 Approved
      request are your financial responsibility.
   2. Surgical requirements such as pet's minimum age, pregnant females, and females in heat vary by                                                      Fee $         Amount from Client
      veterinary practice and are to be discussed at the time the surgery is scheduled. If recently had a                                                               Amount from SNAP
      litter, wait 1-2 months until no longer nursing.                                                                                (Veterinary Hospital)
                                                                                                                                                                                    Total

                                                                                                                                   (Signature of Veterinarian)          Pd. Ch. #                  Date
             PLEASE READ BOTH                                                                                                                                                                             SNC 5/09
SNC 5/09      SIDES CAREFULLY

								
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