Help Companion Animals
P.A.W.S. Colorado
Pets Are Wonderful Support

PO Box 22531

Denver, CO  80222-0531
Phone: 303-693-1587
Fax: 303-693-7110
Providing for the Needs of Companion Animals
Pets are Wonderful Support - Helping Companion Animals




Client Information Form (Confidential)
Red fields are required.
First Name:
Middle Initial:
Last Name:
E-mail Address:
Address:
Address:
City:
State:
Zip Code:
Cross Street:
Phone Number:
Date of Birth:
Are you ambulatory?:
Yes No
Do you have allergies?:
Yes No
In case of emergency, please contact:
Emergency Contact Name:
Emergency Contact Address:
Emergency Contact Phone:
Relationship?:
Secondary Contact Name:
Secondary Contact Address:
Secondary Contact Phone:
Relationship?:
If you have designated an attorney in fact (given power of attorney) for your affairs should you become completely disabled, please list below. (PAWS will require a copy of the Power of Attorney if the attorney in fact should begin to act on your behalf.)
Attorney Contact Name:
Attorney Contact Address:
Attorney City:
Attorney State:
Attorney Zip Code:
Attorney Phone Number:
Have you made arrangements with anyone to care for your animals should you become incapable of caring for them? Yes No
If you have made arrangements with a caregiver, please provide contact information for that person:
Animal Caregiver Contact Name:
Animal Caregiver Phone Number:
Relationship:
Please list a physician that we may contact if there is a medical emergency:
Physician Name:
Physician Phone Number:
If you are being helped by an Social Service agency, please list below:
Agency:
Caseworker Name:
Caseworker Phone Number:
Please indicate whether you have qualified for any of the following:
Medical:
Yes No
SI, SSoc, Disability, SDI:
Yes No
General Assistance (GA):
Yes No
Other:
Yes No
For verification purposes, please enter the numbers you see in the image below:
 
 
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