Application for Assistance With Owned Pets

Date

YYYY

Name of pet owner

First Name

Last Name

Home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Name of pet(s) for whom you need help

Have you received a citation from animal services?

Type of pet

Dog

Cat

Other

Pet's breed

Pet's weight

Pet's gender

Male

Female

Pet's age

Has your pet had any possible exposure to Parvo Virus?

Have any pets in your home had Parvo virus within the last year?

Is pet current on vaccinations?

(Rabies, DA2PPV, FVRCP)

Does your pet have a microchip?

(And is it up to date? If not, please contact your microchip company to update your contact information)

Any health conditions or concerns?

(If so, what?)

Is this an "outdoor" pet?

(Does your pet spend a lot of time in the yard unsupervised (where he/she may be able to mate with a stray))?

How many pets are in your household?

How many pets are in your household are fixed?

How much can you pitch on the vetting cost?

Are you currently employed? If not, are you on disability?

How did you hear about us?

"No Show" Appointments...

Because we value the relationships with our veterinary partners, pet owners MUST show up for scheduled appointments. It is costly and disruptive when scheduled appointments do not show up. If you cannot make a scheduled appointment for whatever reason, please let the clinic know immediately and reschedule the appointment. If you cannot show up for the second appointment, you’ll need to proceed without our assistance. Please type "YES" if you agree to this - Thank you.

Fix’em KC serves the Kansas City Metropolitan area including the counties of Jackson, Clay, Platte, and Cass in Missouri, and Johnson, Wyandotte, Leavenworth, and Miami in Kansas.

Application For Assistance With Owned Pets