PAWS HOOFS AND CLAWS Operation Desex - Phase One - Application for Desexing
APPLICANT DETAILS
First name:
*
Last name:
*
Address:
*
Mobile phone:
*
Email:
Alternate contact person:
Alternative contact phone number:
Are you currently working?
*
Yes
No
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If unemployed, what type of benefit are you on?
Do you hold one of the following concession cards?
QLD Pensioner concession card
Seniors card
Health care card
Veteran card
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Are you in touch with any of the following?
Centacare NQ
NWQICSS
Ngukuthati
Do you have a Case Worker?
*
What is your Case Worker's email:
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What vet clinic do you prefer?
*
Mount Isa Vet Surgery (Ryan Road)
North West Vet Clinic (East Street)
Can you transport your pet to and from the vet (same day)?
*
Yes
No
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ANIMAL #1
Pet name:
Type of pet:
Dog
Cat
How old is the pet?
Breed:
Colour/markings:
Sex:
Male
Female
If female, is your dog on heat/in season or pregnant?
Not pregnant
Pregnant
Maybe pregnant
In season/on heat
Is the pet microchipped?
No
Yes
Unsure
Is the pet registered with the Council?
No
Yes
Unsure
Are there any health issues relating to this pet? If so, please explain:
Is the animal friendly towards ALL people?
Friendly
Not friendly
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ANIMAL #2
Pet name:
Type of pet
Dog
Cat
How old is the pet?
Breed:
Colour/markings:
Sex:
Male
Female
If female, is your dog on heat/in season or pregnant?
Not pregnant
Pregnant
Maybe pregnant
In season/on heat
Is the pet microchipped?
No
Yes
Unsure
Is the pet registered with the Council?
No
Yes
Unsure
Are there any health issues relating to this pet? If so, please explain:
Is the animal friendly towards ALL people?
Friendly
Not friendly
------------------------------------------------------------
ANIMAL #3
Pet name:
Type of pet:
Dog
cat
How old is the pet?
Breed:
Colour/markings
Sex:
Male
Female
If female, is your dog on heat/in season or pregnant?
Not pregnant
Pregnant
Maybe pregnant
In season/on heat
Is the pet microchipped?
No
Yes
Unsure
Is the pet registered with the Council?
No
Yes
Unsure
Are there any health issues relating to this pet? If so, please explain:
Is the animal friendly towards ALL people?
Friendly
Not friendly
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TERMS AND CONDITIONS
Upon submitting this application I agree that ALL the information provided is correct and I confirm I am a resident of Mount Isa City.
*
Yes
No
If required, I agree to provide valid proof of income in order to qualify for the PHC desexing program.
*
Yes
No
I agree for the relevant veterinarian to provide PHC with my animals microchip and desexing information.
*
Yes
No
I understand that completion of this application does not constitute approval. All applications will be reviewed and determined by the PHC Committee who may also seek or hold further discussions with me to determine eligibility.
*
Yes
No
Please call us on 0499 198 949 to collect your form or drop it into the Centacare office (either on Miles Street or Short Street)