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NAME*
First Name Last Name
DATE OF BIRTH*
GENDER*
- Male
- Female
TELEPHONE NUMBER*
ADDRESS*
House / Block Number
*
Street / Road Name
*
Apartment / Unit Number
*
City
*
State / Province / Region
*
Zip / Postal Code
NOW ABOUT YOUR PET
Type of pet(s) owned currently*
- Dog
- Cat
- Both
Is this your first pet?*
- Yes
- No
How many fur kid(s) do you have in total?*
Let us know more about them
Pet 1
- Pet Type*
- Breed*
- Name*
- Gender*
  - Male
  - Female
- Age*
- Birthday*
Pet 2
- Pet Type*
- Breed*
- Name*
- Gender*
  - Male
  - Female
- Age*
- Birthday*
Pet 3
- Pet Type*
- Breed*
- Name*
- Gender*
  - Male
  - Female
- Age*
- Birthday*
Pet 4
- Pet Type*
- Breed*
- Name*
- Gender*
  - Male
  - Female
- Age*
- Birthday*
Pet 5
- Pet Type*
- Breed*
- Name*
- Gender*
  - Male
  - Female
- Age*
- Birthday*
Pet 6
- Pet Type*
- Breed*
- Name*
- Gender*
  - Male
  - Female
- Age*
- Birthday*
Pet 7
- Pet Type*
- Breed*
- Name*
- Gender*
  - Male
  - Female
- Age*
- Birthday*
Pet 8
- Pet Type*
- Breed*
- Name*
- Gender*
  - Male
  - Female
- Age*
- Birthday*
Pet 9
- Pet Type*
- Breed*
- Name*
- Gender*
  - Male
  - Female
- Age*
- Birthday*
Pet 10
- Pet Type*
- Breed*
- Name*
- Gender*
  - Male
  - Female
- Age*
- Birthday*
What brand of food do you currently feed your pet?*
- Wellness
- Holistic Select
- Eaglepack
- Other Brands
Please specify the brand in the text below*
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Email*
Enter Email Confirm Email
Receive notifications from Wellness*
- Yes
- No
CONSENT AND AGREEMENT

*By providing your email address, you agree and consent that you would like to receive our monthly e-newsletter and e-mail notifications, including special offers and new product information through Wellness, please select "No" if you would like to opt out of receiving any notifications from Wellness.
Note: Wellness is committed to protecting you and your pet's privacy. We do not release or sell any personal information to outside companies. For more information, please take a look at our privacy policy.
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