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Please tell us how you heard about us:

Name

Address

City

State

Zipcode

Home phone

Cell phone

Email address

Employer name

Monthly household income

Please describe source of income (employment, social security, disability, etc.)

PROOF OF FINANCIAL HARDSHIP IS REQUIRED (not required for feral requests), such as a recent bank statement, unemployment income, Cal Fresh, etc. Scan and email proof to aaloc@aaloc.org or fax to 714-274-1613 or bonic@hotmail.com.

Pet's name

Breed

Pet type

Cat
Dog
Other

Pet's sex

Male
Female

Pet's age

Pet's approximate weight

List all veterinarians that your pet has seen

Your Financial Responsibility

We receive many calls/emails for help with spay/neuter. It is our desisre to help as many animals as possible. We understand you may be short of funds, but even $25.00 will make a difference and allows us to spay/neuter even more animals. If no co-pay at all is possible, let us know. Otherwise please tell us how much you can afford as a co-pay toward your pet's spay/neuter procedure, pain medications and e-collar if necessary.

Have you applied for Care Credit? If yes, were you approved and for how much?

If you have not applied for Care Credit we suggest that you do so. This credit card allows no interest for 6-12 months. Visit www.carecredit.com or call 800-677-0718 to apply for a Care Credit card.

Two pledges maximum

We will approve a maximum of two pledges at one time. You may reapply for two additional pledges next month; they won't come automatically. Do you need one or two pledges this month?

We work with the following clinics. Please indicate which clinic from the list below you would like to use. (It is advisable to call the clinics to see if they have any appointments available in your expected time frame.)

* Stanton: Stanton Pet Hospital, 8591 Katella Avenue, Stanton, CA 90680 - 714-828-5891 – Please note: domestic cat spay/neuters are a package including pain shot, collar and FVRCP. Cost for a spay is $165.00 and our vouchers cover $90.00. Neuters cost less. Dog prices vary with the age and situation of the dog. Call to verify prices and let us know so we can determine voucher coverage.

* Costa Mesa: Family Animal Hospital, 1525 Mesa Verde Drive East, Costa Mesa, CA 92626 - 714-434-2830 - Please note: this office doesn't take vouchers for feral cats, only domestic cats and dogs. Voucher will pay one-half (1/2) the fee.

* Garden Grove: Brookhaven Pet Hospital, 10092 Chapman Ave., Suite #5, Garden Grove, CA 92840 - 714-530-2200 - Please note: usually there are long waits for appointments at Brookhaven, but ask about cancellations. Brookhaven offers the best prices around and vouchers cover all normal expenses.

* Fountain Valley: Animal Medical Center, 16540 Harbor Blvd., Suite A, Fountain Valley, CA 92708 - 714-531-1155 - Please note: voucher will cover all of basic spay/neuters, but client will pay about $90 for pain injection and take-home pain medications, etc.

* Huntington Beach: Huntington Pet Vet, 20032 Beach Blvd., Huntington Beach, CA 92648 - 714-969-0211 - Please note: this office may, but not always, only take cat vouchers and FVRCP is required (bring proof or get a FVRCP for $15.00 there). The exam is $44.00 but you can make an appointment for procedure only, and not have to pay for an exam. Voucher covers most regular spay/neuter procedures.

* Costa Mesa: Mesa West Pet Hospital, 1870 Placentia Ave., Costa Mesa, CA 92627 - 949-642-9142. - Please note: this office only takes cat vouchers and you will need an exam ($65.00), and proof of vaccinations (which you can get there). One-half of the $182.00 spay/neuter cost and one-half of the take home pain medication is covered by our voucher. You will need to pay about $140.00 after voucher for the cat.

PREGNANT ANIMALS: We do not support the spaying of pregnant animals because it involves the killing of puppies and kittens.

FERAL CATS: We will cover uncomplicated spay/neuter and pain medications at time of surgery for feral cats. A co-payment may be required depending on the vet office and the cat's situation. We'd appreciate any payment toward this spay/neuter you can make, even if our voucher would cover it all. How much could you afford to contribute?

Where are these feral cats located?

I understand that veterinary treatments or spay/neuter surgery has the risk of complications, including death, to my animal. I hereby assume full responsibility for any risk of sickness, injury or death of my animal due to my voluntary participation in the Animal Assistance Program.

I declare under penalty of perjury, that the information provided above is true and correct to the best of my knowledge and I give AALOC permission to verify any information provided by including my signature below.

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