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Request for Low-Cost Vet Care

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Personal Information

* First name

* Last name

* Email

* Email confirmation

Home phone

Cell number

* Current Address

Current Address 2

* Zip

* City

Country

*State/Province

Disclaimer

By requesting low-cost vet care through Bella Vita Animal Rescue Inc, I agree to:
1. Allow my pet to be microchipped.
2. Register the microchip within 2 weeks of the date that my pet receives the microchip.
3. Drop off and pick up my pet on the date of the appointment at the assigned location.
4. Pay as much of my bill as I can comfortably afford.

I agree.I do not agree.

Pet's Information

Pet's name

Pet's species

CatDog

Pet's age / Date of birth

Pet's gender

Intact FemaleSpayed FemaleIntact MaleNeutered MaleNot Sure

Pet's breed

Description (color, pattern, hair length, etc.)

Is this a feral cat?

This is a feral cat and I want to have it ear tipped.This is NOT a feral cat and I do NOT want it ear tipped.This is not a cat.

Vet Care Needed

Cats Only:

I don't have a cat.Spay/NeuterRabies VaccineMicrochipFeline Leukemia VaccineFeline Distemper VaccineHernia RepairNail TrimCombo Test for FeLV & FIVFeral Package (Ear Tip, Spay/Neuter, & Rabies)

Dogs Only:

I don't have a dog.Spay/NeuterRabies VaccineMicrochipCanine Distemper/Parvo VaccineKennel Cough VaccineHernia RepairNail TrimHeartworm Test

Signature

Please type your full name below. By doing so, you agree that you have voluntarily requested vet care and understand that there may be a cost associated with each service.

I have read and agree to the terms and conditions. By checking this box I am confirming that I am 13 years of age or older.

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