Low Cost Qualifier | Mohawk Hudson Humane Society

Vaccination Check

Is your pet up-to-date on their distemper and rabies vaccines?

Yes

No

Your pet must be up-to-date on their distemper AND rabies vaccines prior to scheduling a surgery appointment. Please do not continue filling out this form and instead head to the MHHS Veterinary Services page to self-schedule a vaccine/microchip appointment for your pet and to view any surgery eligibility information. Your surgery appointment will be discussed and/or scheduled at the completion of a vaccine/microchip appointment.

I understand that proof of valid vaccination is required. Valid vaccination is given by a trained professional in a veterinary office or vaccine clinic. Vaccines given at home by owners or by breeders are not accepted.

Primary Owner Information

First

Last

Pronouns

Owner Birth Date

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number (Please Use +1 Before Listing Phone Number)

Phone Number 2

Email Address

Primary Owner ID Type

Primary Owner ID Number

I understand that if I do not bring proof of identification upon being admitted for surgery, MHHS will cancel my appointment and I forfeit any payment provided for services.

Program Eligibility & Pre-Payment

Are you a resident of New York state?

Yes

No

Do you have proof of residency in New York State?

Yes

No

I understand that if I do not bring proof of NYS residency prior to being admitted for surgery, MHHS will cancel my appointment and I forfeit any payment provided for services.

Eligibility Type

I understand that if I do not bring proof of participation (benefit verification letter or ID/Member card) in the above checked program prior to being admitted for surgery, MHHS will cancel my appointment and I forfeit any payment provided for services.

Are you able to make pre-payment in full?

Yes

No

Pre-payment is required for all veterinary services at time of scheduling. You can review our current list of services and costs on our Veterinary Services webpage. Please wait to submit this form until pre-payment can be made for all requested services in full.

Vaccination Check

Primary Owner Information

Program Eligibility & Pre-Payment

Pet Information

Services Request(s)

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Vaccination Check

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Primary Owner Information

Program Eligibility & Pre-Payment

Pet Information

Services Request(s)