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)

Number of Cats

(max 3)

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?

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

I have read & agree to the above policies

First NameLast Name