EmailMe Form - Application for Wobblers Care Package

Pet Owner's Name *

First Last

Email *

Cell Phone *

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Pet's Name *

Pet's Age *

Pet's Gender *

Female

Male

Breed of Pet

Approximate Weight of Pet

Veterinarian/Vet Practice *

Veterinarian's Name *

Vet Phone *

### - ### - ####

Vet Email *

Vet Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Neurologist/Specialist Practice *

Neurologist's Name *

Neurologist Phone *

### - ### - ####

Neurologist Email *

Neurologist Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Date of Diagnosis *

MM / YYYY

How Was Your Pet Diagnosed? *

Did Your Pet Receive and MRI and /or CT?

Please note that an MRI/CT is required in order to be considered for a care package. *

Yes

No

Recommended Treatment Plan *

Acknowledgements & Disclaimer:
Care Package Availability - The amount of items included in our care packages are subject to change at any given time depending on availability of the items from our vendors, shipping/receiving logistical challenges, and the volume of requests for care packages, financial aid, and successful fundraising activities. By submitting an application for a care package, you acknowledge that approval and/or the availability of all items may not be guaranteed.
Care of Pet - Captain's Salute is comprised of volunteers; we are not licensed veterinarians or vet technicians. Any advice provided by Captain's Salute is solely based on personal experiences with Captain's care and shared experiences from other #TeamCaptain Wobblers families and should not be deemed as a recommendation of care for your pet. Recommendations for your pet's care should be provided to you by your veterinarian.

Please check the box below to indicate you have read and understand the previous statements and that you acknowledge the information in your application is truthful. *

I have read and understand the above and acknowledge the information on my application is truthful.