Veterinarian Participation Form

Practice Name

Veterinarian's Name

Contact Name

Address

City

State

Zip

Phone

Fax

Days Open

Hours Open

Rates

I agree to provide spay/neuter operations at low cost for persons bringing in a SpayUSA referral certificate(s). My special prices for these clients are as follows:

Dogs

	Weight Range	Male Dog	Female Dog	Pregnant Female Dog
1
2
3
4
5
6

Cats

	Male Cat	Female Cat	Pregnant Female Cat
1

Feral Cats

We Work With Stray/Feral Cats: Yes No

Pricing (if different from house cat pricing):

	Male Cat	Female Cat	Pregnant Female Cat
1

Additional

Are these your regular prices or do referrals need a SpayUSA certificate?

Additional charge for female cat in heat:

Additional charge for female dog in heat:

Additional charge for overweight cats:

Additional charge for overweight dogs:

Additional charge for undescended testicles:

Other additional charges:

Charge for vaccinations for cats:

Charge for vaccinations for dogs:

Charge for Rabies vaccinations for cats:

Charge for Rabies vaccinations for dogs:

Additional charge for Feleuk testing:

Other additional charges:

Program Specific Restrictions

Would you like to be listed on our website? Yes No

By checking the box below and submitting this form, you are agreeing to the following terms.

I agree to provide spay/neuter operations at low cost for persons bringing in SpayUSA referral certificate(s). My special prices for these clients are listed on this form.

Additional fees for complications will be discussed with the pet owners prior to surgery.

I agree to retain the redemption certificates and return them to SpayUSA periodically for statistical evaluation.

SpayUSA will instruct clients to call two weeks in advance for an appointment, and to pay for services when the animal is dropped off for surgery.

I have a right to discontinue participation in the network at any time by notifying SpayUSA.

I agree to the terms above: