Salutation * Please select...MrMsMrsMiss
First Name *
Last Name *
Pet’s Name *
E-Mail *
Mobile
Other Phone
Address *
How did you hear about us? please select...Word of MouthInternet SearchFacebookAdvertisementOther
Pet Type please select...DogCatOther
Pet Breed
Pet Sex
Spayed/Neutered? please select...YesNo
Pet Colour
Distinguishing Features
City Registration Number
Rabies Vaccine? please select...YesNo
Microchipped? please select...YesNo
Microchip Number (if applicable)
FOB Provided? please select...YesNo
Feeding Instructions (Amount, Time, etc) *
Treats Allowed? Brand(s)?
Allergies or Food Restrictions?
Medical Concerns or Issues?
Current Medications and Doses
Describe any past aggression issues
My pet loves to...
My pet hates to...
Additional Information
Pet Birthday
Vet Name or Clinic
Vet Address
Vet Phone
Preferred Doctor
I hereby give Urban Tail my express permission to transport any of my pets for care to the above-mention veterinarian( or closet open facility if the Primary Vet office is not available). I give permission for the hospital/clinic/doctor to administer any care or medications necessary. I understand the Urban Tail will try to contact me a soon as possible in the event of a medical emergency. please select...YesNo
If Urban Tail cannot contact me, I give permission to Urban Tail to approve treatment up to (please enter amount in the text box): *
Read our Terms and Conditions Here
This authorized document gives urban tail/lori blair authorization to enter the above address as need to perform the necessary service.
By clicking the box below, you are accepting all of the above mentioned Terms and Conditions, understanding and acknowledging the equivalence of a personal signature.
I understand and Accept Terms (check box) *
