New Client Form

New Client Form
Name

First NameLast Name
Other Adult Household Members (full name)
Email
None if no email
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
Number of Dogs
(Max 3)
Dogs Name Breed Weight Age (Y/M) How long have you owned? (please indicate y=years, m=months)
Dogs Name Breed Weight Age (Y/M) How long have you owned? (please indicate y=years, m=months)
Dogs Name Breed Weight Age (Y/M) How long have you owned? (please indicate y=years, m=months)
Number of Cats
(max 3)
Cats Name Age How long have you owned? (please indicate y=years, m=months)
Cats Name Age How long have you owned? (please indicate y=years, m=months)
Cats Name Age How long have you owned? (please indicate y=years, m=months)
Other Pets
Are all of your pets spayed/neutered? (fixed)
If you have pets that are not yet fixed, how much can you afford to put toward their surgery(s)? (N/A if all are fixed)
We work with C-Snip and Fur Wellness. Dog spay/neuter is $155 (C-Snip), cat spay/neuter is $75 (C-Snip). How much of that, if any, can you afford per pet?
Please list all pets that are not fixed
N/A if all are fixed
What type of food do your pets prefer?

Other
Do any of your pets have special dietary needs?
If so, please list. (We are completely donation based so we cannot promise anything specific but we can always look)
Waiver & release of liability
Pantry Guidelines/Rules
Spay/Neuter
New Pets
Donation/Volunteer Based
Need Based
Do you authorize anyone else to pick up for you

Yes, list name
Questions/Comments
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I have read & agree to the above policies

First NameLast Name
Should be Empty: