New Client Form

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
Dogs Name Weight Age How long have you owned? Breed
Dogs Name Weight Age How long have you owned? Breed
Dogs Name Weight Age How long have you owned? Breed
Number of Cats*
0 if no cats
Cats Name Weight Age How long have you owned?
Cats Name Weight Age How long have you owned?
Cats Name Weight Age How long have you owned?
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 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?
What type of food do your pets prefer?*

Dry DogCanned DogDry CatCanned CatCat - Combo (50/50)Dog - Combo (50/50)Other
Do any of your pets have special dietary needs? Do they eat more wet than dry, or dry than wet?
If so, please list. (We are completely donation based so we cannot promise anything specific but we can always look)
Waiver & release of liability*

I give electronic consent that I've read the form and agree.
Pantry Guidelines/Rules*

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.
Annual Registration*

I agree to complete a new registration annually.
Questions/Comments
Date

MonthDayYear
Date
I have read & agree to the above policies

First NameLast Name
Should be Empty: