Wellness Clinics Application Please fill out the form to apply for either a Spay/Neuter Clinic and/or Wellness and Vaccination Clinic. NOTE: We will only be in touch with approved clients. Qualifications: Animals must be between 2 months to 6 years of age. Animals must be healthy: no nasal or ocular discharge/sneezing, or showing obvious lameness. No visibly ill animals. The applicant owns the animal. For companion animals only. Animals intended for sale will not qualify. Applicants must provide proof of income below $57,909 (Market Basket Measure verification). Acceptable documents include: Notice of Assessment Low-income documentation Pay slips indicating annual income About YouYour Name(Required) First Last Your Address(Required) Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Please select the age range that applies to you(Required) 18-24 25-40 41-54 55+ Email(Required) Phone number(Required)Proof of Market Basket Measure Status(Required)Max. file size: 50 MB.This clinic is intended for individuals below the Market Bucket Measure threshold. In Alberta, this measure is $57,909.00. To qualify for the clinic, your annual income must be below $57,909 per year. Please upload your most recent Notice of Assessment as proof of this measure. Please know this record will be verified by Calgary Humane Society staff, after which time it will be securely discarded by Calgary Humane Society.Clinic TypeWhich clinic are you applying for?(Required) Spay/Neuter Clinic Wellness and Vaccination Clinic Select all that apply.About Your Animal:Animal Name(Required)What kind of animal are you enrolling?(Required) Cat Dog Please indicate what breed of dog:(Required)Sex(Required) Male-Neutered Male-Intact Female - Spayed Female-Intact AgeYears(Required)Please enter a number less than or equal to 20.Months(Required)Please enter a number less than or equal to 12.Weeks(Required)Is your animal healthy?(Required) Yes No Is this animal intended for sale?(Required) Yes No Are there any additional health conditions or allergies we should be aware of?(Required) Yes No Is your pet on any medication?(Required) Yes No Please indicate what medication they are receiving.(Required)Tell us why you are applying for Calgary Humane Society’s No Cost Spay/Neuter and/or Wellness Clinic:(Required)Are you currently on a waitlist for any other spay/neuter progam:(Required) Yes No Do you have secure housing with your pet?(Required) Rent with landlord permission Rent without landlord permission Own home Currently unhoused Facing eviction Is your eviction related to your pet?(Required) Yes No Vet HistoryDoes your pet have a current regular veterinarian?(Required) Yes No What clinic do you attend?(Required)What was the date of your last vet visit?(Required) MM slash DD slash YYYY Is your pet in heat?(Required) Yes No Vaccine History WELLNESS AND VACCINE CLINIC: A core combination vaccination will be given to each animal. This will require a booster 2 weeks following the initial vaccine. This will be the responsibility of the owner to schedule, and at their own cost. Please note, this vaccine clinic does NOT include a rabies vaccination.SPAY/NEUTER CLINIC:A core combination vaccination will be given upon recovery from anesthesia (DA2PP or FVRCP). If your animal is up to date on vaccinations, please provide proof of vaccination (attach medical file). If this is not received, your animal will be vaccinated. Please note, this vaccine clinic does NOT include a rabies vaccination.What (if any) vaccines has your pet received?(Required)Please provide proof of vaccination Please Attach your Animal's medical fileMax. file size: 50 MB.Has your pet had a reaction to a vaccine?(Required) Yes No Your animal will be housed in a separate kennel from other animals. Vaccination is not a requirement for either Spay/Neuter or the Wellness and Vaccination clinic. By submitting this application, you acknowledge there is a risk of exposure of your animal to infectious disease. If your animal is unvaccinated your animal is at increased risk.Behaviour InformationHas your pet ever shown aggressive behaviours (growl, snap, bite, hiss, swat)?(Required) Yes No Please describe(Required)Does your dog need to be muzzled at the vet?(Required) Yes No Has your pet bitten and broken skin in the last 10 days?(Required) Yes No Does your dog demonstrate reactivity (barking, lunging, growling, etc..) towards other animals?(Required) Yes No Please provide any additional details to keep both you and your pet safe at the clinic:(Required)Additional SupportPlease select any other supports you may be seeking:(Required) Food Bank Behaviour Support (describe behaviour concerns you are facing) Facing eviction due to pet’s behaviour Surrender If you selected any of the above, please describe the concerns you are facing:(Required)If internal or external media relations are present at the clinic I am attending with my pet: I opt IN to my pet being on video or photographed for public release I opt OUT to my pet being video or photographed for public release I opt IN to being on video or interviewed about my experiences with the Calgary Humane Society Community Clinics I opt OUT to being on video or interviewed about my experiences with the Calgary Humane Society Community Clinics Please note that media may or may not be present at each clinic, and opting in does not guarantee your image will be used. Opting in simply provides Calgary Humane Society clarity on those granting permission to be used if necessary.