New Customer Registration Form
Fairclough Industries, LLC (Doing Business as Perfect Pooch AZ)
Date
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Dog's Name(s) [Please list all dogs]
*
Age of Dog(s)
0 - 6mo
6mo - 1 year
1 year - 3 years
3 years - 7 years
7 years +
Dogs' Gender(s)
*
Male
Female
Breed(s)
*
Is your dog...
*
Current on shots
Spay or Neutered
Overall Healthy
Rescue Dog
List some behaviors you would like to address.
*
How did you hear about us?
*
Please Select
Google Search
Other Online Search
Friend/Family Referral
Social Media
Veterinary Hospital / Pet Store
Flier/Broshure
Other
Please Specify
*
Vaccination Records
Browse Files
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of
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*
Acknowledgement and Acceptance I have read and understand this Release of Liability. I voluntarily agree to its terms, acknowledging the risks involved and waiving my right to hold Fairclough Industries, LLC (Perfect Pooch AZ) liable for any incidents as described above.
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*
I Acknowledge and Accept that I have read and understand the Terms and Conditions.
Signature
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