Survey - Request for Low-Income Medical Services at Angell at Essex

Request for Low-Income Medical Services at Angell at Essex

Please provide the following information about yourself (parent/guardian) and your household. Please note that proof of residence will be required at your appointment. We will call you within 1-2 business days to schedule your pet's appointment.

About You

Name:

First Required	Last Required

Email: Required

Street 1: Required

Street 2:

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number: Required

Yes, I would like to receive e-mail from MSPCA-Angell

Yes, I would like to receive postal mail from MSPCA-Angell

Keep me logged in. What's this?

Question - Not Required - Please indicate your pronouns (ex. she/her, he/him, they/them, etc)

*3.

Question - Required - Please indicate how you qualify for Low-Income services (select all that apply):
Please make up to 7 selections from the choices below.

	SNAP
	WIC
	EBT
	Section 8 or other government-subsidized housing
	Government heating/fuel assistance
	Income at or below 200% of the federal poverty level, based on taxes and household size (1040 form)
	Massachusetts Animal Fund Spay/Neuter voucher

*4.

Question - Required - Pet's Name

*5.

Question - Required - Pet's Species (we only accept dogs and cats at this time) Canine
Feline

*6.

Question - Required - Pet's Sex Male
Female

*7.

Question - Required - Is your pet neutered/spayed or intact? Neutered/spayed
Intact (not neutered or spayed)

*8.

Question - Required - Breed:

*9.

Question - Required - What is the reason for your visit? (healthy/update vaccines, pre-spay/neuter, sick visit, etc.) (Please note that we cannot provide emergency care and typically book 4-8 weeks out for new patient visits. If your pet is urgently sick, we advise that you seek medical care sooner, such as from Angell's Emergency Service.)

*10.

Question - Required - Does your pet have any pre-existing medical conditions (if yes, please provide details):

We will require documentation for public assistance programs and a rabies certificate if your pet already has a current rabies vaccine or has ever received a rabies vaccination.

If you have further pets that require care, please fill out a separate application for each pet.

We will call you within 1-2 business days to schedule an appointment. Please be aware that our services are in very high demand, and we will do our very best to contact you promptly.

Thank you for your interest and support of our programs!

The Mission of the Massachusetts Society for the Prevention of Cruelty to Animals-Angell Animal Medical Center is to protect animals, relieve their suffering, advance their health and welfare, prevent cruelty and work for a just and compassionate society.