Fill Out Completely and M A I L to FOGAS P.O.Box 1557 Guthrie Ok. 73044
For more info: call Von Coburn@ . or call 405.282.1520
FOGAS is a small local organization made up entirely of unpaid volunteers.
This program is funded solely by donations.
Combined household income per month $__________________ Number of people in household ____________________
How many pets do you own________________ Do you rent or own your home: _______
Animal Name:___________________________ Color____________ Breed__________________________________ weight____________
What kind of animal: dog or cat - male or female Has this animal been seen by a Vet:_______ Who:_______________
A completely filled out application MUST BE Mailed to the above address! If you do not mail your application
—we will void your application!
Proof of residence maybe be required. A Friends of Guthrie Animals Inc. Board member may call you. Be sure to put a daytime phone.
Please allow 2 to 4 weeks for voucher to be mailed to Vet. The Vet will call you to set up surgery appointment. Invalid 30 days from date on voucher issue.
This certificate is null and void if tail docking, ear cropping or any other mutilating procedure is done at time of the spaying/neutering.
Your Copayment is based on your application and choice of Vet.
I hereby give consent and authorize surgical sterilization of my pet and I understand the procedure.'
I also understand there are certain risks and complications associated with any operation or procedure of this type.
I further understand that, during the course of the surgery, unforeseen conditions may arise that may necessitate the
performance of additional procedures. I agree to pay the agreed co-payment to the participating veterinarian
at the time of surgery and agree to have the surgical procedure performed within 30 days of FOGAS approval date.
I am the legal owner of the animal described above and I have the legal authority to execute this consent agreement.
The above information is true and correct to the best of my knowledge.
Signature of Owner X__________________________________________________Date__________
Please indicate what you can pay towards the surgery: ____________
Vet and FOGAS to fill out only
Please check for FOGAS SEAL to ensure this is a valid voucher
Seal of FOGAS approval_________________dated___________
Signature of Vet that they have surgically sterilized the described animals on this date.
Vet spay/neuter charge $________
Less 20% discount (-) $________
Less co pay (-) $________
Amount billed to FOGAS $_______ _
Animal weight________ _____ Pregnant/ in heat ____________________
FOGAS will have to approval any additional charges PRIOR to Surgery if female is pregnant or in heat.
No approval—no payment
Please return all paperwork with billing.