First Name*

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Operation Pets Alive
Public Spay and Neuter Program

Veterinarians and Rescue Groups working together to save lives!

Thank you for your interest in OPA's Public S/N Program for residents of Montgomery County, TX only. (Proof of residency will be required.) Our partnering Veterinarians are working with OPA to offer low-cost services to you & to help Montgomery County remain a no-kill community! Please say THANK YOU to our supporting veterinary hospitals and let us know how this program has helped you by emailing info@operationpetsalive.org!

Name of pet*

Do you believe this pet might show aggression to the veterinary staff?

Is the animal in heat?

Is the animal pregnant?

Has your pet ever had an allergic reaction to any medications or anesthesia?

If so, what?

Is the animal a dog or a cat?

Is the pet a male or female?*

What is the breed or breed mix?

What is the pet's approximate age (note years or months)?

How much does the pet weigh (in pounds)?*

Are the pet's vaccinations up to date? (Required by the veterinarians. Dogs: current on Parvo/Distemper (DAPP) and Bordatella vaccines. Cats: current on FVRCP. If not current, they are offered at low-cost through this program and are given at the time of service by the vet.)*

Are the pet's rabies vaccination up to date? (Required by the veterinarians for both dogs and cats. If not current, they are offered at low-cost through this program and are given at time of service by the vet.)*

Is the pet on heartworm preventative? (Heartworm disease is easy to prevent and expensive to treat. Please check the HTW status of your pet yearly and keep them on a preventative.)*

Is the pet microchipped? (A microchip will assure that your pet is returned to you if it strays or is taken to a shelter.)

Is your annual household income less than $40,000 per year?*

Are you on financial assistance (EBT or Wic, Medicaid, Medicare, Supplemental Security Income Program, Unemployment)*

Applicant comments

Services Requested

Please indicate all of the services requested for this pet by checking the boxes below.  Do not make payments at this time. You will be contacted by an OPA representative after the application is submitted.

If selecting PLAN A, you must have answered YES to one or both of the last two questions.

Dog Services Costs:

Cat Service Costs:

Paying by
Choose one: Paypal Money Order Credit Card (Visa, Mastercard, American Express)

Do not pay at this time. When you receive an email from the OPA representative to pay, click on the "Spay/Neuter Fees" drop down box to make your selection. When you click on the "Buy Now" box, it will take you to the Paypal screen and you can pay using Paypal or a credit card.

If paying by Money Order, please send to Public S/N Program, P.O. Box 132104, Woodlands, TX 77393 along with your printed application and other required documents (application, proof of residency & if qualified for Plan A proof of income and/or government assistance).

Possible Additional Charges

These are possible additional costs applicable to dogs or cats which would be paid to the veterinary hospital directly at checkout at time of surgery if applicable. (The cost may be more or less than stated here and can be changed by the veterinarian at any time without notice to OPA)

• $26.00 additional for females who are determined to be in heat at the time of surgery.
• $36.00 additional for females who are determined to be in late-term pregnancy at the time of surgery.
• $77.00 additional for males who are determined to have undescended testicles at the time of surgery.
• $7.00 additional for any animal with fleas at the time of surgery.

Do you agree to pay the specified additional charges at time of service should they be applicable to your pet?*

I UNDERSTAND THAT ALL SURGERY AND ANESTHESIA CARRIES RISKS, and that unforeseen conditions may be present which can increase the risks of complication during or after surgery.. I understand that animals of advanced age, that have heartworm disease or that have never been vaccinated carry increased risks. I agree not to hold the participating veterinarian(s) or their representative(s), the participating animal rescue group or their representative(s), and volunteers or the facility liable for damages. If the veterinarian deems that the animal is not in condition to undergo surgery, surgery will not be performed. If I choose to use the services of an emergency clinic I understand that I will do so at my own expense. I certify that all information regarding my animal and my income is correct and true to the best of my knowledge.

By typing my name below, I attest that I agree to all terms and conditions set out in this contract.*

Date

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