Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Have you brought an animal to the Corbin Animal Wellness before? *

Yes
No

Are you filling out this application for yourself or someone else? *

Self
Someone else

If someone else please provide your name, phone number and relation:

**You must be already receiving some type of government assistance from the state of KY to be applicable for the low-cost voucher program. Examples include, SNAP, low-cost housing, Medicaid, a child in the home receiving KCHIP, LIHEAP, etc. *

I have read and understand.

Please upload a copy of proof of government assistance below. The proof of government assistance must match the name, address, and phone number of the applicants name for the low-cost voucher program. *

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

INFORMATION REGARDING THE ANIMAL BEING APPLIED FOR

Pet's Name *

Species *

Dog
Cat

Sex *

Male
Female

Breed *

Color *

Estimated weight of pet *

Approximate age or birthdate *

Any previous or ongoing medical problems? *

Current Medications? *

There is a limit of two (2) vouchers per household per quarter. Voucher Prices are all inclusive, including the actual surgery, all medications needed, Rabies vaccine, and overnight stay. Take home pain medications, and Cones will be available for additional charges. *

I have read and understand.

If you schedule and do not show up for you appointment without calling to reschedule 48 hours in advance you will not be able to reschedule and will not be eligible for vouchers in the future. *

I have read and understand.

Payment will be collected before appointments are created. *

I have read and understand.

PRICING

Cat Spays (Female): $100.00

Cat Neuter (Male): $75.00

Dog Spay (Female): $135.00 (If in heat or pregnant $40.00 will be added at time of surgery to be paid at discharge)

Dog Neuter (Male): $115.00

You will be emailed a link to the email you have provided from Calendly.com to schedule your own appointment, after your application has been reviewed (surgery dates will only be Monday-Thursday). You will pay for your appointment at the time you schedule. If you are not approved, you will receive an email explaining why. *

I have read and understand.

Please allow at least 5 business days for your application to be approved.

As this is a new program we are creating to further assist our community, please be patient as we work out the kinks.

I have provided accurate information to the best of my knowledge, I have read, understand, and agree to all the statements above. *

I have read and understand.

Corbin Animal Health & Wellness

Low Cost Vouchers Form

Low Cost Vouchers Form

INFORMATION REGARDING THE ANIMAL BEING APPLIED FOR

PRICING

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