New Jersey Department of Health

Infectious and Zoonotic Diseases Program

PO Box 369

Trenton, NJ 08625-0369

APPLICATION AND CONSENT FOR STERILIZATION OF PETS	TO BE COMPLETED BY VETERINARIAN
Pre-Surgical Authorization
Number:
Date:
This sterilization falls under New Jersey Public Laws (P. L. 1983, Chapter 172, P. L. 1986, Chapter 192, P. L. 1989, Chapter 238 and P. L. 1991, Chapter 405) and attendant regulations in the New Jersey Administrative Code. Any falsification of information on this or related documents is punishable by fines under the penalty enforcement law.
PART I ‑ CLIENT / PET INFORMATION
1. Name of Pet Owner (Last, First, MI)

2. Home Telephone Number

3. Street Address	City	County	State	Zip Code

4. Ownership

1 Owner	2 Proxy (Proxy Authorization Form MUST BE ATTACHED)
5. From What Source Was Pet Obtained?

1 Pet Shop	2 Shelter/Pound	3 Kennel/Private Breeder	4 Friend/Relative	5 Other
6. Programs Under Which Eligibility is Claimed
1 Food Stamps	7 Lifeline Credit
2 Supplemental Security Income	8 Tenants Lifeline Assistance
3 Aid to Families with Dependent Children (ADC)	9 Medicaid
4 General Public Assistance (Welfare)	10 Shelter/Pound Adoption Program
5 Pharmaceutical Assistance to the Aged and Disabled	Date of Adoption:
6 Rental Assistance	Facility/Agency Code Number:
7. Type of Pet

1 Male Dog	2 Female Dog	3 Male Cat	4 Female Cat
8. Is Pet Licensed?
1 Yes ‑ License Number:	2 No
9. Name of Pet

10. Breed

11. Weight

Lbs.	12. Age

Years
I HEREBY CONSENT TO THE PRE‑SURGICAL IMMUNIZATION, IF REQUIRED, AND STERILIZATION OF THE PET DESCRIBED ABOVE AND ATTEST THAT THE INFORMATION ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE
Signature of Pet Owner or Authorized Representative	Date
PART II ‑ VETERINARIAN INFORMATION
13. Name of N. J. Licensed Veterinarian (Last, First, MI)

14. Name of Business/Hospital

15. Business Telephone Number

( )
16. Type Vaccination Administered

17. Date of Vaccination

18. Date of Sterilization

19. Co‑Payment Fee Paid for Sterilization

1 $10 (Social Services Program)	2 $20 (Shelter/Pound Adoption Program)
CERTIFICATION:	I HEREBY CERTIFY THAT THE CLIENT IS ELIGIBLE UNDER THE PROGRAM CHECKED ABOVE AND HAS PRESENTED THE PROPER IDENTIFICATION. THE CO‑PAYMENT FEES WILL BE FOR THE ENTIRE SURGICAL PROCEDURE WHICH SHALL MEAN HEREIN EXAMINATIONS, IMMUNIZATION, SPAYING/NEUTERING, MAINTENANCE, DISCHARGE, REMOVAL OF SUTURES, AND POST-SURGICAL COMPLICATIONS. I HEREBY ATTEST THAT THE IMMUNIZATION AND/OR STERILIZATION OF THE ANIMAL DESCRIBED ABOVE WAS CARRIED OUT AS RECORDED.
Signature of Veterinarian	Date
Signature of Pet Owner or Authorized Representative	Date
APC-5

AUG 12	Distribution: Original to NJDOH when Completed

APC-5, Application and Consent for Sterilization of Pets

APC-5, sterilization, pets, IZDP, zoonotic, veterinarian

Elaine White

2012-03-15

ewhite

NJDOH