FIXING IT 2025 Appointment Intake Form

Appointment Request Form
Name*

FirstLast
Email*
example@example.com
Cell Number*
Please enter a textable phone number.
Address*

Street Address

Street Address Line 2

CityState
Zip Code*
Distance Fee
You are outside of our service area. Appointments may still be available on a case by case basis.*

I understand and would still like to complete this form.
Family Information*
Please tell us a little about who else lives in your home - spouse, children, other pets, etc.

Pet's Information
Pet's Name*
Type of Pet*
Gender*
Breed*
(Approximate) Age*
Weight (round up to the nearest 5lb)*
ex. if weight is 18lb, put 20 etc.
Color*
(Optional) Photo of Pet
Euthanasia Cost

$450$475$500$525$550$600
Additional Information*
Please us know what is going on with your pet and anything you would like us to know.
Primary Veterinary Clinic
If none, write n/a
Primary Veterinary Phone*
Please enter a valid phone number.
Specialty Veterinary Clinic
If none, write n/a
Specialty Veterinary Phone*
Please enter a valid phone number.

Enter coupon

Appointment Request Form