NEW CUSTOMER REGISTRATION AND AGREEMENT FORM
Kindly complete all the relevant sections and submit to register
Customer Information
Your Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Emergency Contact Number
Please enter a valid phone number.
Email Address
*
example@example.com
Secondary Email Address
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Dogs Details
Your Dogs - For each additional dog click Add button below
*
Up to date with all required vaccinations: Rabies, Kennel Cough and "5-in-1"?
*
Yes
No
To be updated
Please attach a copy of each dog's vaccination card here.
Browse Files
Drag and drop files here
Choose a file
Note that the total attachment size is limited to 4 MB
Cancel
of
Health, Food, Feed and Happiness
Any medical conditions or recent injuries or illnesses?
*
Any allergies or food sensitivities?
*
Brief information about food and feeding patterns
*
Note that owner to provide own food. Doggobone Raw and UCN Kibble may also be purchased through Dogshop@Zimzala
Allowed treats?
Yes
No
Any additional notes about your dogs behaviour (aggressive tendencies, resource guarding, level of obedience and etc.)
*
Vet Details
Vet Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Address
Practice Name, Street Address, .....
Street Address Line 2
City
State / Province
Postal / Zip Code
Agreement and Submission
Date
-
Month
-
Day
Year
Date
Your Signature
Submit
Should be Empty: