CONTACT INFORMATION

Applicant First and Last Name (required)

Street Address (required)

Suite, Condo, Apt.

City (required)

State (required)

Zip (required)

Home Phone (required)

Work Phone

Cell Phone

Your Email (required)

Are you employed?
 Yes No

Employer

If you are not employed, what is your source of income?

PET'S INFORMATION

Pet(s) Name(s):

Is your pet a dog or cat?

Breed(s):

Approximate Age(s):

Approximate Weight(s):

Has your pet(s) been spayed or neutered?

*If your pet is not altered, we require this be completed upon conclusion of treatment(s). You must be willing to agree to this stipulation.

Is your pet current on vaccinations?

Does your pet spend the majority of its time indoors?

VETERINARIAN REFERENCE
If you do not have a veterinarian we may contact, please list three references below.

Clinic Name:

Address:

Phone:

PERSONAL REFERENCES

Reference 1 Name:

Email:

Home Phone:

Work Phone:

Cell Phone:

Reference 2 Name:

Email:

Home Phone:

Work Phone:

Cell Phone:

Reference 3 Name:
(Only needed if no vet reference is given).

Email:

Home Phone:

Work Phone:

Cell Phone:

IF YOUR PET NEEDS VACCINATIONS, WHICH ONES ARE YOU REQUESTING?

Rabies:  Yes No For how many pets?
*Please note that Virginia Code requires proof of a current rabies vaccination for every cat/dog over 16 weeks old.

Distemper:  Yes No For how many pets?

Canine Bordetella:  Yes No For how many pets?

Feline Leukemia:  Yes No For how many pets?

IF YOU PET NEEDS TESTS, WHICH ONES ARE YOU REQUESTING?

Heartworm Test:  Yes No For how many pets?

FeLV/FIV Combo Test:  Yes No For how many pets?
*Please note that a current FeLV/FIV test should be on file before administration of this vaccine.

Fecal Test:  Yes No For how many pets?

IF YOU PET NEEDS MONTHLY PREVENTIONS, WHICH ONES ARE YOU REQUESTING?

Heartworm Prevention:  Yes No For how many pets?

Flea and Tick Prevention:  Yes No For how many pets?
*Please note that current heartworm test results must be provided. If this has not been conducted within the last 12 months, veterinarians require a new test to be performed.

IF YOU PET NEEDS A MEDICAL PROCEDURE/TREATMENT, PLEASE DESCRIBE BELOW?

What is your pet's illness or injury?

What is your pet's diagnosis?

What treatment is needed and/or what treatment has your pet already received?

Any other information we should know?

Who is the attending veterinarian?

*Please note that we may recommend treatment with a clinic that regularly performs services for us.

Please scan and upload a written estimate from the veterinarian who will be treating your pet for its current condition.

FINANCIAL INFORMATION?

What portion of the pet’s care can you pay for yourself, if any?

What circumstances are necessitating financial aid?

Would you have transportation to Norfolk or Virginia Beach for treatment/transfer of supplies?
 Yes No