Friends of Guthrie Animals, Inc. 
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Spay and Neuter Application                                                                         

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.

 

 

 

 

 

 

Name:_________________________________________________________________________

Daytime phone__________________________________________________________________

Address:__________________________________________________________

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___________
    X____________________________________  
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.

 

 

 

 

 

 

 

 

 

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