How Was your purchase made?
*
Please Select
Groupon
website
Mobile App
Social Media
Purchase Information
Purchase Date
*
-
Month
-
Day
Year
Groupon Voucher #
Purchasers' Name
*
First Name
Last Name
Purchaser's Phone #
*
-
Purchaser's Email
*
example@example.com
# Animals Registering
*
Please Select
1
2
Animal 1 Details
A2 Registration Number
Animal 1 First Name
*
Animal 1 Last Name
*
Animal 1 Birth Date
*
/
Month
/
Day
Year
Animal 1 Species (dog or cat)
*
Animal 1 Breed
*
Animal 1 weight
*
Animal 1 Gender
*
Male
Female
Animal 1 Training Status
*
Please Select
Not Started
In Training
Fully Trained
Animal 1 Support Type
*
Please Select
Emotional Support Animal (ESA)
Psychiatric Support Animal (PSA)
Service Animal
Animal 1 Photo
*
Browse Files
Drag and drop files here
Choose a file
(Portrait Layout)
Cancel
of
Animal 2 Details
Animal 2 First Name
Animal 2 Last Name
Animal 2 Birth Date
/
Month
/
Day
Year
Animal 2 Weight
lbs
Animal 2 Species
(dog or cat)
Animal 2 Breed
Animal 2 Gender
Male
Female
Animal 2 Training Status
Please Select
Not Started
In Training
Fully Trained
Animal 2 Support Type
Please Select
Emotional Support Animal (ESA)
Psychiatric Support Animal (PSA)
Animal 2 Photo
Browse Files
Drag and drop files here
Choose a file
(Portrait Layout)
Cancel
of
Handler Details
Handler First Name
*
Handler Last Name
*
Handler Birth Date
*
/
Month
/
Day
Year
Handler Phone Number
*
-
Handler Email
*
Handler Address
*
Handler City
*
Handler State
*
Handler zip
*
Handler Photo
*
Browse Files
Drag and drop files here
Choose a file
(Portrait Layout)
Cancel
of
How would you rate your experience with us?
*
1
2
3
4
5
feedback welcome!
Newsletter Information
Would you like your support animal’s name to be included in our monthly newsletter under ‘New Support Animal Members’ to help celebrate their registration?
Please Select
Yes, please include my animal’s name
No, I prefer to keep it private
If this is left blank we will automatically add your support animal to the newsletter.
Submit
Should be Empty: