*Agency Name:
Public E-mail:
Mailing Address
*Address L1:
Address L2:
*City:    *State:     *Zip:
Physical Address         address same as mailing?
*Primary Phone:
*Address Line 1:
Address Line 2:
*City:   *State:      *Zip:
Website:
(please include http)
We are:       
We offer or refer spay/neuter services:         
Average Price for the following ("Large" and "Small/Medium" vary by agency. "Large" might be considered 70 lbs. and "Medium" 40 lbs.)
If you provide vouchers, certificates or discounts only, please estimate what the average price in your community for a spay/neuter surgery would be after the application of your voucher, certificate or discount. If you do not know, please estimate.
Large
male dog
$
Large
female dog
$
Small/Medium
 male dog
$
Small/Medium
 female dog
$
Large
male cat
$
Large
female cat
$
Small/Medium
 male cat
$
Small/Medium
 female cat
$
What type of agency are you?
Do you alter or refer for alter feral/free-roaming cats?       
Do you eartip feral cats?
Do you alter or refer pediatric patients (defined as under 6 months of age)?       
What is the lowest age/weight that you will alter or refer for alter?
Do you have additional required charges beyond the spay/neuter surgery (example: exam, blood work, vaccinations)?       
If you have additional required charges, please list the total dollar fee and description of what the charge is for.
How many dogs and cats do you alter or refer annually?
Is spay/neuter your primary service and focus?       
Are you a full-service veterinary clinic?       
Do you provide limited wellness services with spay/neuter surgery?       
Do you work with rescues/shelters to provide s/n for their adoptable animals?        
Do you offer discounts below your regular pricing for any of the following:
   Low Income clients       
   Feral cat caretakers       
   Rescues/Shelters       
   Other
Exclusions
  Are there any types of animals that you won't spay/neuter (assuming animal is otherwise healthy)?
  Exclusions Other:
ASPCA / PetSmart Newsletter
Check any of the Newsletters you would like to receive
Who is submitting this request?
First Name:   Last Name:
Internal E-mail:             
* By checking here, your clinic is seeking and agreeing to be listed in the PetSmart Charities and ASPCA Free or Low-Cost Spay/Neuter Database housed on the PetSmart Charities and ASPCA websites. Websites supported by other animal welfare organizations may also include a link to the database on their websites. Third parties may access the database and view the information that you have provided, and you acknowledge and agree that neither PetSmart Charities, Inc. nor the ASPCA can monitor the usage of your information by such third parties. You hereby verify that you are authorized to submit your information to this database, and the information you have provided is true, complete and accurate to the best of your knowledge. YOU EXPRESSLY UNDERSTAND AND AGREE THAT PETSMART CHARITIES, INC., AND THE AMERICAN SOCIETY FOR THE PREVENTION OF CRUELTY TO ANIMALS AND THEIR SUBSIDIARIES, AFFILIATES, OFFICERS, EMPLOYEES, AGENTS, PARTNERS AND LICENSORS SHALL NOT BE LIABLE TO YOU FOR ANY PUNITIVE INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL OR EXEMPLARY DAMAGES, INCLUDING, BUT NOT LIMITED TO DAMAGES FOR LOSS OF PROFITS, GOODWILL, USE, DATA OR OTHER INTANGIBLE LOSSES (EVEN IF PETSMART CHARITIES, INC. AND THE AMERICAN SOCIETY FOR THE PREVENTION OF CRUELTY TO ANIMALS HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES). RESULTING FROM: (A) THE USE OR THE INABILITY TO USE THE SERVICE; (B) THE COST OF PROCUREMENT OF SUBSTITUTE GOODS AND SERVICES; (C) UNAUTHORIZED ACCESS TO OR ALTERATION OF YOUR TRANSMISSION OR DATA; (D) STATEMENTS OR CONDUCT OF ANY THIRD PARTY ON THE SERVICE OR; (E) ANY OTHER MATTER RELATING TO THE SERVICE.