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

1.

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 The MSPCA-Angell

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

Keep me logged in. What's this?

2.

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). Note that income qualifying documents (SNAP/WIC card, housing letter, IRS 1040 form, etc.) as well as a matching photo ID will be required at all appointments in order for us to provide low cost care.
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 to schedule as appointments become available. Please be aware that our low cost services are in very high demand, and there is currently a 4- to 8-week wait time for an appointment.

Thank you for your interest and support of our programs!