IMPORTANT!!! *

Before you fill this form please note that someone from the medical team will contact you during our opening hours and this can sometimes take over 48 hours. Please do not use this helpline if this is a medical emergency.

I understand the terms

Name *

First Name

Last Name

Phone *

(###)

###

####

Pet Name *

First Name

Last Name

Please check all applicable boxes *

My Pet is

Dewormed in the last 3 months

Flea & Tick treated within the last 3 months

Heart worm Treated

Vaccinated within 12 months

Please check all applicable boxes *

My pet has been experiencing the following symptoms

Vomiting

Diarrhoea

Limping

Breathing Difficulties

Hair Loss (Mange | Redness)

Bloody Stools

Worms present in pet stool

Itchy Ears

Open Wounds

Dog or Cat Bite

Other

Liability Waiver *

I agree to hold Pacific Animal Shelter and Hospital (PASH) harmless from any and all claims, loss or damage, liabilities and costs, including attorney’s fees, as a result of my participation in this Activity (including advice received from PASH), including travel to and from the Activity or any events incidental to this Activity. If PASH incurs any of these types of expenses, I agree to reimburse PASH.

I agree