New Client Form

New Client Form
Name*

First NameLast Name
Other Adult Household Members (full name)
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.Format: (000) 000-0000.
How did you hear about us?*
Number of Dogs
(Max 3)
Dogs Name Weight Age Breed How long have you owned? (please indicate y=years, m=months)
Dogs Name Weight Age Breed How long have you owned? (please indicate y=years, m=months)
Dogs Name Weight Age Breed How long have you owned? (please indicate y=years, m=months)
Number of Cats
(max 3)
Cats Name Weight Age How long have you owned? (please indicate y=years, m=months)
Cats Name Weight Age How long have you owned? (please indicate y=years, m=months)
Cats Name Weight Age How long have you owned? (please indicate y=years, m=months)
Other Pets
Yes, all of my pets (proof will be required within 30 days)No, none of my pets (spay/neuter required within 60 days)Some of my pets (spay/neuter required within 60 days)
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?
Dry DogCanned DogDry CatCanned CatCat - Combo (50/50)*Dog - Combo (50/50)*Other
*Do they eat more wet than dry, or dry than wet?
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*
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 within 30 days OR get a spay/neuter appointment within 60 days of signing up.
I understand that I will no longer be eligible for assistance if I add any new pets to my household.
I understand that PHPFP is completely volunteer run & donation based. They cannot guarantee any specific type or amount of food/supplies.
I agree to only come as needed & take only what I need.
Questions/Comments
Date

MonthDayYear
Date
I have read & agree to the above policies

First NameLast Name
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