New Client (with pets) Registration
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number (please include the country code)
*
May we contact you via WhatsApp
*
Yes
No
Is there another method of contact that we should use for you (ie Facebook messenger)?
By default, De Fiets- en Hondenstop will contact you via email to the address you provided above and will use your phone number to call you, leave a voicemail, and/or send you text and/or WhatsApp messages unless otherwise requested. We will also add your email address to our newsletter mailing list automatically. Please note that in cases of emergency, we may override your contact requests in an attempt to contact you.
*
I agree
I don't agree
Your Billing Address
*
Country
Street Address
City
State / Province
Postal Code
Address where services will take place (if applicable) - Please indicate 'De Fiets- en Hondenstop' if services will take place at our location and 'online' if services are digital only.
Country
Street Address
City
State / Province
Postal Code
Emergency Contact Information
Please choose an emergency contact that we can reach if you are not available.
Emergency Contact's name, phone number, email, and city of residence
*
Billing Information
By default, De Fiets- en Hondenstop will invoice NL and EU clients; invoice requests will be made viaemail and will include options to pay via iDEAL, PayPal, or through direct transfer via IBAN number.Clients based out of the US will be invoiced via email with a request to pay via PayPal, in which credit ordebit card payments are possible as well. Where applicable, please indicate the sliding scale rate thatyou will be paying for our services. Invoices are based on services that have already taken place in thetime between the last invoice date and the current one and are sent at the end of each month.
Please indicate which of the following is applicable to you
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I am a NL client
I am an EU client
I am a US client
I am a client outside of the NL/EU/or US
Vet Information
Vet Clinic (and name of Vet if known)
*
Vet Clinic's Address
*
Vet Clinic's phone number
*
Vet Clinic's email Address
Back
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Pet Information
Please note, you may register 2 pets with us at once. If you have additional pets, we will accept those on a case-by-case basis
What type of animal is pet 1
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Dog
Cat
Small Animal
Pet 1's Name
*
Please share the following information about pet 1: breed, sex, age, coloring, and weight (in kg)
*
Has Pet 1 been microchipped?
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Yes
No
I'm not sure
Has pet 1 been spayed/neutered
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Yes
No
No, but I plan to
Does pet 1 have any medical issues we should be aware of, and if so, please list and any treatment involved.
Please provide the dates of pet 1's most recent vaccinations (and the vaccination received)
*
Please indicate which (if any) apply to pet 1 (Please note, we may ask you for further information, though none of the below will automatically disqualify your pet from care)
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Receives anti flea/tick medications
Has had previous training
Pees and/or defecates in the house
Is clicker trained
Is crate/bench trained
Barks excessively
Has been injured by another dog
Has caused injury to another dog (or person)
Is NOT comfortable around other dogs
Is NOT comfortable around children
Is trained in another language other than English
Can receive treats
None of the above apply to Pet 1
Do you have another pet you would like to register with us?
*
Yes
No
Pet 2 Information
Please note, you may register 2 pets with us at once. If you have additional pets, we will accept those on a case-by-case basis
What type of animal is pet 2
*
Dog
Cat
Small Animal
Pet 2's Name
*
Please share the following information about pet 2: breed, sex, age, coloring, and weight (in kg)
*
Has Pet 2 been microchipped?
*
Yes
No
I'm not sure
Has pet 2 been spayed/neutered
*
Yes
No
No, but I plan to
Does pet 2 have any medical issues we should be aware of, and if so, please list and any treatment involved.
Please provide the dates of pet 2's most recent vaccinations (and the vaccination received)
*
Please indicate which (if any) apply to pet 2 (Please note, we may ask you for further information, though none of the below will automatically disqualify your pet from care)
*
Receives anti flea/tick medications
Has had previous training
Pees and/or defecates in the house
Is clicker trained
Is crate/bench trained
Barks excessively
Has been injured by another dog
Has caused injury to another dog (or person)
Is NOT comfortable around other dogs
Is NOT comfortable around children
Is trained in another language other than English
Can receive treats
None of the above apply to Pet 2
Please Sign to ensure the information you've provided is accurate to the best of your knowledge
*
Please type your full name
*
Your location
*
Today's date
*
Submit
Submit
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