PAWS ON WHEELS, LLC

Pets on a roll          where they need to go

We need to have your information before we can transport your pet.

  I. CLIENT INFORMATION  
 
Name(s):    
Address:    
City:    
State:    
Zip:    
Home Phone:    
Cell Phone:    
Work Phone:    
Email address:    
Emergency contact name:    
      a. Phone:    
      b. Relation to you:    
      c. Does this person have a key to your home?     Yes    No
      d. Which door?    

Please list contacts that have keys to your home:

   
Emergency contact name:    
       a. Contact phone:    
      b. Relation to you:    
      c. Which door?    
Emergency contact name:    
      a. Contact phone:    
      b. Relation to you:    
      c. Which door?    
Emergency contact name:    
      a Contact phone:    
      b. Relation to you:    
Which door?    

II. AUTHORIZATION AND CONSENT    

I give Paws on Wheels permission to transport my pet(s) I agree   I do not agree
I understand the POW assumes no responsibility I agree   I do not agree
I understand that POW is a transport service I agree   I do not agree
I have made advance arrangements to pay I will make arrangements
I can not made arrangements
This form wil be retained on file with POW I agree   I do not agree
This consent for treatment and authorization has no expiration I agree   I do not agree
POW will pick up my pet(s) the day of service & someone will be at home. Yes, pick up my pet
No, this is not my choice
      a. Please give us the name of who will be home.    
POW will be picking up a key prior to the day of service & will return the key when services are completed. Yes, pick up my key prior to the day
No, this is not my choice
       a. Date    
       b. Time    
       c. Where should we leave the key if you are not home?    
I will be signing up for Paws On Wheels Secured Key arrangement Program. Yes, I will be sign up for the Key Program
No, this is not my choice
      Notes and Comments