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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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