New Client Form

Name*

First NameLast Name

Other Household Members

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

None if no email

Phone Number*

Please enter a valid phone number.

How did you hear about us?*

Number of Dogs*

0 if no dogs

Dog Information (Name, Age, Breed, Weight)*

N/A if no dogs

Number of Cats*

0 if no cats

Cat Information (Name, Age, Type)*

N/A if no cats

Other Pets

Are all of your pets spayed/neutered? (fixed)*

Yes, all of my petsNo, none of my petsSome of my pets

Please list all pets that are not fixed *

N/A if all are 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 exclusively. Dog spay/neuter is $125, cat spay/neuter is $55. How much of that, if any, can you afford per pet?

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)

Let us know what type of food your pets eat.*

All dry food/kibble, all wet/canned food, some of each, etc...

Waiver & release of liability*

I give electronic consent that I've read the form and agree.

Spay/Neuter*

I understand that PHPFP requires all pets to be spayed/neutered unless medically unsafe. (If you need financial assistance please let us know!)I understand & agree to provide proof of spay/neuter OR get a spay/neuter appointment within 30 days of signing up.

New Pets*

I understand that I will no longer be eligible for assistance if I add any new pets to my household.

Donation/Volunteer Based*

I understand that PHPFP is completely volunteer run & donation based. They cannot guarantee any specific type or amount of food/supplies.

Need Based*

I agree to only come as needed & take only what I need.

Questions/Comments

Date

I have read & agree to the above policies

First NameLast Name