Quick Fix Appointment Scheduling Survey

1. Please provide your contact information:

Please provide your contact information: Name (first AND last):
Address:
Address 2:
City/Town:
Zip/Postal Code:
State:
Home Phone:
Work Phone:
Cell Phone:
Email:

Please provide the information requested below for the FIRST pet you wish to schedule; you will have the opportunity to add additional pets later in the questionnaire.

2. Please provide first pet's name:

Please provide first pet's name:

3. Please provide your pet's age:

Please provide your pet's age:

4. Species

Species Cat	Dog
Other (please specify)

5. Sex:

Sex: Male

Female

Not sure

6. Color(s):

Color(s):

7. How much does this pet weigh?

How much does this pet weigh?

8. If a CAT, describe breed type:

If a CAT, describe breed type: Domestic Long Hair

Domestic Medium Hair

Domestic Short Hair

Siamese type

9. If a DOG, describe breed type (beagle, lab, etc or your best guess of what the mix might be)

If a DOG, describe breed type (beagle, lab, etc or your best guess of what the mix might be)

10. Does this pet have a current rabies vaccination? (copy of certificate required, or $10 charge for vaccination at time of surgery).

Does this pet have a current rabies vaccination? (copy of certificate required, or $10 charge for vaccination at time of surgery). Yes

No

Other (please specify)

11. If your pet is scheduled for the Alabama Spay/Neuter Clinic, Calera Animal Hospital, or Animal House there will be an additional $5 charge for capstar to kill fleas.

If your pet is scheduled for the Alabama Spay/Neuter Clinic, Calera Animal Hospital, or Animal House there will be an additional $5 charge for capstar to kill fleas. I acknowledge the add'l $5 charge for surgeries scheduled at Irondale, Calera Animal Hospital or Animal House

12. Has this pet had any litters?

Has this pet had any litters? No

1

2

3 or more

13. If yes, what happened to those litters?

If yes, what happened to those litters? Sold Gave Away	Still have Took to a shelter
Other (please specify)

14. How many other pets do you have?

	0	1	2	3	4 or more
Dogs	How many other pets do you have? Dogs 0	Dogs 1	Dogs 2	Dogs 3	Dogs 4 or more
Cats	Cats 0	Cats 1	Cats 2	Cats 3	Cats 4 or more
Other	Other 0	Other 1	Other 2	Other 3	Other 4 or more

15. Are the other pets already spayed/neutered?

Are the other pets already spayed/neutered? Yes

Some are, some aren't

No

No other pets

16. Do you have another pet to schedule for surgery?

Do you have another pet to schedule for surgery? Yes

No

Quick Fix Appointment Scheduling
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1. Quick Fix Appointment Scheduling

Quick Fix Appointment Scheduling
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