4630 Martin Road
Cumming GA 30041

Phone:
770/887-1565

Fax:
770/781-4237
 

All material contained in this site (including Project Spay Neuter)
are the sole property of Pet Vet
and may not be used without our express permission.

Application for Low-Income Spay Subsidy Program

This program provides subsidies for spaying female dogs & cats. The co-payment is  $15.00 with the covered by Pet Vet and Dr. Land. Due to dwindling funds, male dogs and cats are not currently eligible for this program.

In order to qualify, you MUST show proof of financial need. Please attach a copy of proof of eligibility. This can be any of the following: your welfare, Medicaid, food stamps or WIC card, a stub from an unemployment check, a determination letter from SSI Disability. Social Security alone is not a qualification, unless social security is your ONLY income. A copy of last year’s tax returns is required to verify that you have no other income. If you didn’t meet the requirements for filing a tax return last year, provide a copy of your last three months bank statements showing the deposit of your social security check. Your signature below will be considered a sworn statement of no other income.

Even if another group or person has offered to make your co-payment for you, it will have to be paid when the animal is picked up. We cannot afford to do the bookkeeping required to bill for co-payments under this program. Please contact the group or individual helping you and arrange to either have the $15.00 with you or pay it yourself and make arrangements with them to be reimbursed later.

You must have subsidy approval BEFORE scheduling your appointment. Fill in this form, print it out and fax it (770/781-4237) or bring it/mail it (4630 Martin Road, Cumming GA 30041) with all the other required documentation to the clinic. Please give us 10 business days before calling to check on your approval status. If you have been approved, you will be able to schedule your appointment at that time.

Name:    _________________________________   Phone: _______________

Address: _________________________________________________________

City/State/Zip:  ___________________________________________________
 

Due to funding constraints, we must limit this program
to 3 animals per residence.
 

Pet 1: _________________________________  Cat ______ Dog ______

Pet 2: _________________________________  Cat ______ Dog ______

Pet 3: _________________________________  Cat ______ Dog ______

I certify that the animal(s) named above is/are my personal pet(s).
I understand that the $15.00 co-payment is due when the animal(s) is/are picked up.

Signature: _____________________________________ Date:  __________________

Site Maintained by: Tracy Land, DVM
Page Rev. 04/02/07