Name *

First Name

Last Name

Phone Number *

Please be sure to provide a phone number where you are reachable and the voicemail box is set up.

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Pet Medical Status *

Check the following that apply for your pets.

Check if your pet/pets are current on heartworm prevention

Check if your pet/pets are on flea/tick prevention

Check if your pet/pets are current on vaccines

Check if none of these apply

Dog Vaccines *

Please select which vaccines your dog/dogs has had within the last year.

Rabies

Distemper

Leptospira

DAAP or DHPP

Bortdella

Influenza

None of these

Not Applying for Dog Voucher

Requirements *

Check to confirm you are in financial hardship or need, and cannot otherwise afford the cost of a spay/neuter.

Check to confirm that you are the owner of the pets listed above.

Check to confirm that you are 18 years of age, and that all of the information provided is true to the best of your recollection and knowledge.

Check to confirm that all pets listed above are older then 8 weeks old.

Check to confirm that you understand that the state of Alabama requires that all pets must be vaccinated annually against rabies. If your pet has not had rabies, the vet may require you purchase the vaccine in order to participate in the spay/neuter voucher program.

Check to confirm you understand that the voucher covers the cost of spay/neuter surgery and anesthesia ONLY.

Check to confirm the owner does not hold FAVOR or the practicing vet responsible for any and all rare side effects or damages suffered by owner, pet, and any third party resulting from the medical services for this pet.

Signature *

By typing your name below, you are electronically signing this application.

First Name

Last Name

Today's Date *

MM

DD

YYYY