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MASH Form (April 26-27) – WELLNESS APPOINTMENTS
Do you receive government subsidy, or have an Indigenous status card?
(Required)
Yes
No
Thank you for your interest in this clinic. This clinic is an initiative in partnership with Akwesasne First Nation Community and open to their community members. If you are not a member of Akwesasne First Nation Community, please keep an eye on our website for future clinics in your area.
Animal Owner's Name
(Required)
First
Last
Animal Owner's Address
(Required)
Street Address
Address Line 2
City
Province
ZIP / Postal Code
Daytime Phone Number
(Required)
Secondary Phone Number
Email
(Required)
Species
(Required)
Cat
Dog
Animal's Name
(Required)
Animal's Age
(Required)
Please enter a number from
1
to
5
.
1-5 years of age
Breed
(Required)
Sex
(Required)
Male
Female
Unsure (if checked, an appointment to confirm sex will be booked prior to surgical appointment)
If male, have both testicles descended? (confirm this by seeing and feeling both testicles)
(Required)
Yes
No
Please advise us of any medical conditions past or present (seizures, skin condition, heart murmur etc ..)
(Required)
Please provide us with the name of your Regular Veterinarian or Veterinary Clinic
(Required)
Does your cat meet the "ideal" body condition as per the charts linked below?
(Required)
Yes
No
Unsure
Cat Body Condition Chart
Does your dog meet the "ideal" body condition as per the charts linked below?
(Required)
Yes
No
Unsure
Large Dog Body Condition Chart
Small Dog Body Condition Chart
Consent
(Required)
I acknowledge that this spay/neuter request is for our MASH-style mobile clinic in Cornwall Island
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