YOUR PUPPY'S NAME: ______________________________________________________________________________________________________
DATE PURCHASED:
_________________________________________ AMOUNT
PAID: _____________________________________________
WAS THE PUPPY 'ON SALE' OR AVAILABLE AT A REDUCED PRICE? YES ______ NO ______
HOW DID YOU PAY? CREDIT CARD? YES ______ NO ______ CHECK? YES ______ NO ______ CASH? YES ______ NO ______
AGE OF PUPPY AT TIME OF PURCHASE: _______________________
BREED: _____________________________________________________
SEX: ______________________ DISTINGUISHING MARKS:
_____________________________________________________________________
WAS THE PUPPY SPAYED OR NEUTERED? YES ______ NO ______
DO YOU KNOW WHERE YOUR PUPPY WAS BORN? YES ______ NO ______ DID YOU TOUR THE FACILITY? YES ______ NO ______
WHERE DID YOU PICK UP YOUR PUPPY? STORE
________ BREEDER'S HOME __________ AIRPORT
_________ OTHER __________
DID YOU RECEIVE PAPERWORK AT THE TIME OF
PURCHASE? YES
______ NO ______
DID YOU SIGN A CONTRACT? YES ______ NO ______ DID YOU RECEIVE A HEALTH GUARANTEE? YES ______ NO ______
DID YOU RECEIVE MEDICAL RECORDS FOR YOUR PUPPY AT THE TIME OF PURCHASE? YES ______ NO ______
DID YOU RECEIVE PAPERWORK TO REGISTER YOUR PUPPY AT THE TIME OF PURCHASE? YES ______ NO ______
WHAT REGISTERY WAS IT? __________________________________ DID YOU FILE THE PAPERS? YES ______ NO ______
DID YOU TAKE YOUR PUPPY TO THE VET PRIOR TO HIM/HER BECOMING ILL? YES ______ NO ______
DID THE PET STORE REQUEST YOU TAKE YOUR PUPPY TO THEIR VET? YES ______ NO ______ DID YOU? YES ______ NO ______
NAME OF THEIR VETERINARIAN: __________________________________________PHONE NUMBER: ______________________________
ADDRESS: ________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
WHEN DID YOUR PUPPY BEGIN TO EXHIBIT SYMPTOMS OF ILLNESS: ________________________________________________________
WHAT SYMPTOMS DID YOUR PUPPY HAVE: _________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
DID YOU TAKE YOUR PUPPY TO THE VET AFTER BECOMING ILL? YES ______ NO ______
NAME OF YOUR VETERINARIAN: ___________________________________________________________________________________________
ADDRESS: _________________________________________________________________________________________________________________
TELEPHONE NUMBER: ____________________________________________________________________
IS YOUR PUPPY CURRENTLY LIVING WITH YOU? YES ______ NO ______ IF NO, DID YOUR PUPPY DIE? YES ______ NO ______
HOW OLD WAS YOUR PUPPY AT THE TIME OF DEATH? ______________________________________________________________________
DID YOUR VET PROVIDE YOU WITH A DIAGNOSIS? YES ______ NO ______
WHAT WAS IT? ___________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
DID YOUR VET PROVIDE YOU WITH A 'NOT FIT FOR SALE' CERTIFICATE? YES ______ NO ______
WHAT ARE YOUR VETERINARY BILLS TO DATE?
__________________________________________________________________________
WILL YOUR PUPPY REQUIRE ADDITIONAL MEDICAL CARE OR SURGERY? YES ______ NO ______
HAVE YOU CONTACTED A LAWYER? YES ______ NO ______
HAVE YOU CONTACTED OTHER CONSUMER AGENCIES? YES ______ NO ______
ADDITIONAL COMMENTS: ________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
PLEASE PRINT OUT THIS FORM AND FILL IT OUT COMPLETELY - IF YOU DON'T KNOW AN ANSWER, LEAVE IT BLANK
IF ADDITIONAL SPACE IS NEEDED, PLEASE ATTACH A SEPARATE SHEET
MAIL THIS FORM, ALONG WITH ALL OTHER REQUESTED DOCUMENTATION TO:
NORTH PENN PUPPY MILL WATCH
P.O. BOX 1012
LANSDALE PA 19446
THANK YOU!