Animal Friends: Survey - Request a Spay/Neuter Coupon: Dog

Request a Spay/Neuter Coupon: Dog

*1.

Question - Required - Do you live in southwestern Pennsylvania? If you answer yes, please continue. (If your answer is no, you are not in our service area. Please refer to http://www.spayusa.org)

*2.

Question - Required - Who owns this dog? I am the owner.
It's a neighborhood stray.
None of the above

*3.

Question - Required - Where did you get your dog?

	Shelter
	Breeder
	Pet Store
	Newspaper Ad
	Rescue Group
	From someone I know
	Was a stray
	Other

*4.

Question - Required - How old is this dog? Under 6 months
6 months - 1 year
1 - 3 years
Over 3 years

*5.

Question - Required - What other pets live in your household?
Please make at least 1 selection from the choices below.

	Dog
	Cat
	Other
	I have no other pets.

*6.

Question - Required - Has your dog had previous litters?

7.

Question - Not Required - Are your other pets already altered? (Skip this question if you have no other pets.) Yes
No

*8.

Question - Required - Are you interested in information about spay/neutering multiple animals? (NOTE: If you are applying to have multiple animals spayed or neutered, you may reprint your coupon up to five times. If you need assistance with more than five surgeries, please contact us at 1-800-SPAY-PGH.) Yes, please contact me.
No

*9.

Question - Required - Why are you planning to alter your pet(s)? (Select all that apply)
Please make at least 1 selection from the choices below.

	I spay/neuter all of my pets.
	It's the right thing to do.
	My vet recommended it.
	I care about the health of my pet.
	I don't want kitten/puppies.
	To reduce behavioral issues, spraying, roaming, etc.

*10.

Question - Required - How did you hear about our program? Advertisement
Animal Friends website
Referred by friend, neighbor, coworker
Called looking for assistance
Other

*11.

Question - Required - Have you used our program in the past?

12.

Question - Not Required - If yes, tell us about your experience. (Leave blank if you answered "no" to the previous question.)

(Maximum response 255 chars, approx. 5 rows of text)

13.

Question - Not Required - Please share any comments and suggestions that might strengthen our program.

(Maximum response 255 chars, approx. 5 rows of text)

14.

Please provide your contact information.

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number:

Yes, I would like to receive e-mail from Animal Friends

Yes, I would like to receive postal mail from Animal Friends

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