Low-Cost Voucher Application Tell us about you and your dog. Your Name* First Last Preferred Contact Number*Cell PhoneHome PhoneCell Phone*Home Phone*Email Address* Address* Street Address City State / Province / Region ZIP / Postal Code Mailing AddressDo you have a veterinarian?*YesNoName of Veterinarian or Vet clinic*Dog Name*Age in Years*01234567891011121314Age in Months*0123456789101112Weight (or best guess)*Breed (or best guess)*Color and identifiable markings*Sex*MaleFemaleHas your dog given birth?*YesNoWhat is the most recent year your dog gave birth?20192018201720162015201420132012201120102009200820072006How many litters has your dog had?123456789101112Is she pregnant?YesNoHow many weeks?Is she currently in heat?YesNoHave both of his testicles dropped?YesNoIs your dog up to date on their rabies vaccine?*YesNoYear of last vaccine*2021202020192018201720162015201420132012201120102009200820072006Is your dog up to date on their Da2pp vaccine?*YesNoYear of last vaccine*2021202020192018201720162015201420132012201120102009200820072006Would you like us to administer the Da2pp vaccine? It is included in the co-pay.Has your dog ever been tested for heart worm?*YesNoYear of testing*2021202020192018201720162015201420132012201120102009200820072006Is your dog on heartworm preventative?*YesNoHas your dog had any health issues?*YesNoExplain*Is your dog obese?*YesNoAny abnormal behavior, coughing, sneezing, diarrhea or vomiting?*YesNoExplain*Is your dog aggressive toward humans?*YesNoIs your dog aggressive toward other dogs?*YesNoDoes your dog live...*IndoorsOutdoorsBothIs your dog chained?*YesNoNotesCAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.