EmailMe Form

Key

Processor

Todays Date *

MM / DD / YYYY

Please use two digits for month and day - 01-02-03-04-05-06.

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

County *

Phone *

### - ### - ####

Confirm

### - ### - ####

Email *

Confirm

If you belong to Facebook, please add your page link here.

Log into Facebook, then click on your name in the upper right part of the screen. Copy the Facebook Profile URL in the address bar of your browser

Dogs Name *

Dogs Age *

Dogs Weight *

Dog is a *

Male - Neuter

Female - Spay

Dogs Breed *

Where was this dog acquired from? (For example; Rescue or Shelter’s name, Breeder’s name, Family member, Friend, found as a stray, etc.) *

How long have you had the dog? *

Is this dog owned by you or with a rescue organization? *

Owned

Rescue Organization

If this is your personal dog please select owned. If the dog is currently with a rescue organization please select rescue organization.

Is this dog up for adoption? *

YES

NO

If up for adoption please include Organization Name or NONE if no organization. *

501c3?

Yes

No

Veterinary - Hospital - Clinic Information

Where surgery will take place.

Veterinarian's Name , Hospital/Clinic Name and complete address.

***Please include
Veterinarians Name
Clinic Name
Street Address
City State Zipcode

LCO

Veterinary Phone Number: *

### - ### - ####

Veterinary Contact Name:

Is your dog up-to-date on vaccines? if not which vaccines does your dog need. Check ALL that apply.

Dog is Current on Vaccines

NEEDS-Rabies

NEEDS-Puppy DHPP: vaccines for Distemper, Adenovirus (Hepatitis), Parainfluenza and Parvovirus

NEEDS-Adult DHPP: vaccines for Distemper, Adenovirus (Hepatitis), Parainfluenza and Parvovirus

Cost of Surgery? *

Upload a detailed estimate from a Veterinarian Clinic *

Contact a local low cost vet clinic in your area, request an estimate, scan or photograph and upload here.

Amount you are requesting? *

Amount you are able to contribute? *

Total Household Gross Annual Income *

Numeric

Number of Persons in Household *

Does your household receive any public assistance? *

Yes

No

If yes, what type of assistance?

Is this an EMERGENCY surgery? *

NO

YES

If this is an emergency, please explain the emergency

PYOMETRA SECTION QUESTIONS

Only complete the next 4 questions if your dog has been diagnosed with PYOMETRA. Otherwse, jump to the end of section and complete the rest of form.

How long has your dog had Pyometra symptoms?

When (date) was she diagnosed?

Where (clinic name, phone #) was she diagnosed?

Is your dog on antibiotics and, if so, how long has she been taking them?

End of PYOMETRA Section

Continue completing the remainder of the form below.

Have you contacted low cost spay/neuter resources for your area? *

Yes

No

Have you applied previously with PBRC for assistance? *

Yes

No

MANDATORY RESPONSE REQUIRED:

You will receive an automatic email at the email address you supplied. Please check all folders (including Spam and Junk folders).

You are REQUIRED to reply to the automatic email you receive within 24 hours to start the funding process.

If you choose not to respond, PBRC will automatically withdraw your application.

Your participation in looking for low-cost options in your area, contacting them, and relaying the detailed information back to PBRC for funding consideration is expected and required.

Your full participation in communication via email is REQUIRED throughout the process through completion. Please check the statement(s) below indicating that you understand these requirements so PBRC may proceed with your application process. *

I agree to email communication and will respond to automated the email within 24 hours.

I agree and understand that if I do not respond to the automated email (within 24 hours) PBRC will withdraw my application.

I agree and understand that PBRC does not reimburse. All funding must be pre-approved and we only pay the vet clinic directly.

In order to receive funding we must receive a clear, good quality close-up photo of the dogs's face and body. This upload allows for multiple photos.

Photo Upload of Dog (REQUIRED) *

Upload allows for multiple photos, if request is for Mom and pups or for more than one dog.

I understand PBRC may use the photo of my dog to further it's mission. *

Yes

How did you hear about our spay/neuter program? *

Name of Individual or group or Google search.

Section Break

A description of the section goes here.