CLIENT INFORMATION FORM

CLIENT INFORMATION FORM This agreement, dated ________________ is made between PETS 911 Inc., whose address is 626 RXR Plaza Uniondale, NY 11556, referred to as “Pets 911 Inc”, and the client_____________________________.

Please fill out the following:

OWNER

First Name:_____________________

Last Name: _____________________

Street:___________________________________________________
Apt#:______

City, State:________________________________________________

Zip:__________

Home Phone: ______________________________________________
Emergency Phone:____________________________ Work Phone:______________________

Pet’s Regular Veterinarian Name: ______________________________________
Address:_____________________________________
____________________________________________
Phone: ______________________________________

How did you hear about us?

Payment is expected when services are rendered. Please check your preferred method of payment: CASH_________MONEY ORDER___________AMEX___________VISA___________MC__________DISC__________
Credit Card #:_______________________________________________Expiration# _________ Date:_____________________________

Current Employer: ____________________________________________________________________ ____________________________________________________________________________________
____________________________________________________________________________________

FEES: PAYMENT IS DUE WHEN SERVICES ARE RENDERED. QUOTED FEES ARE FOR ONE WAY PET TRANSPORT ONLY. ROUND TRIP FARES ARE SEPARATE AND ADDITIONAL. PETS RESCUE 911 CHARGES A MINIMUM FLAT FEE REGARDLESS OF THE TIME SPENT OR DISTANCE TRAVELLED DURING TRANSPORT.
I, _________________________________, have read, understand and agree that the promised service to be provided by PETS RESCUE 911 Inc. is as follows:

TRANSPORT FORM

Pick Up Location: ____________________________
____________________________
____________________________
Destination: ___________________________
___________________________
___________________________

[ ] One Way Non-Emergency Transport (curbside pickup & transport of caged animal) $150.00
[ ] Additional Fees (ie: waiting time, oxygen, medical services etc.) _____________________________
[ ] Up to 60 LBS or requiring 1 person handler’s assistance (+$100.00)
[ ] 61 – 100 LBS or requiring 2 person handler’s assistance (+$130.00)
[ ] 101 – 120 LBS or requiring Vet Tech Team (+$150.00)
[ ] 121 LBS + or requiring Vet Tech Team (+$200.00)
[ ] Round Trip Transport Requested _________
[ ] Additional Services _______________________________________________________________
[ ] TOTAL _________
_____________________ understand, agree and affirm that the above information is accurate in that it may be relied on by PETS RESCUE 911 Inc., its employees, agents and veterinary professionals in the treatment of the above forementioned pet or animal. Initial: _____

I authorize PETS RESCUE 911 Inc. to transport the above-mentioned pet or animal and to use all reasonable precautions against injury, escape or death, and you release and hold harmless PETS RESCUE 911 Inc., its employees and agents for any injury, escape or death. Initial: _____

I accept full and complete responsibility for any errors or omissions and hold harmless PETS RESCUE 911 Inc., its employees, and agents for any errors or omissions arising before, during or after the transport of the above forementioned pet or animal. Initial: _____

I do hereby remise, release, acquit, PETS RESCUE 911 Inc. satisfy, and forever discharge PETS RESCUE 911 Inc., its employees, or agents of and from all manner of action(s), cause(s) of action, suits, debts, sums of money, accounts, controversies, agreements, promises, damages, judgments, executions, claims and demands whatsoever, in law or in equity, which You shall or may have, by reason of any matter or cause.
Initial: _____

I understand and agree that PETS RESCUE 911 Inc. provides pet transportation only and does not provide any medical or veterinary treatment, diagnosis, medication or prescriptions of any kind. Upon request by me, veterinary professionals are available for an additional fee to accompany my pet or animal during transit to provide any medical or veterinary assistance. Initial: _____

Print Name: _____________________ Signature: _____________________ Date: ______________

PET INFORMATION FORM

Pet’s Name:_____________________________________________________________________

DOG__________ CAT__________ BIRD__________HORSE___________OTHER_______________

Breed:_________________________ Age: Sex: Neutered:

Is your pet current on vaccinations?
Vaccination: ____________________ Date: _____________________

Vaccination: ____________________ Date: _____________________

Any pre-existing medical conditions or allergies? _____________________________________________________________________________________

_____________________________________________________________________________________

Reason for your call today?

_____________________________________________________________________________________

CLIENT INFORMATION FORM

OWNER

TRANSPORT FORM

PET INFORMATION FORM

THANK YOU TO OUR SPONSORS