Pet Evaluation Questionnaire for PermaStay

Pet Evaluation Questionnaire

Please read the instructions below and then fill out this questionnaire and click “Send” at the bottom.

In order to determine if your pet is suitable for PermaStay please complete the fields below and click the send button at the bottom. Do not include photo(s) when the ear is standing. The photos should show the pets ear in its most morbid state. We will provide a referral to a Certified PermaStay Facility in your area or region and will be available to answer any questions or concerns you may have. Your pet’s profile and photos will be provided to the Certified PermaStay facility so when calling for a formal evaluation with the referral surgeon they will know the details of your pet.

Instructions:

Complete Questionnaire below and click SEND at the bottom..

Allow from 1 to 24 hours for your pet’s review If you do not get a response within 24 hours PLEASE let us know,
Do NOT include photos of the pet’s ear taped or temporarily standing.
Be precise on information provided as reviews are based on your data you provide.
Completing the form indicates that you are ready to proceed. If not, please submit the form when you are,

PermaStay Evaluation

Name(Required)

First Last

Email(Required)

Phone(Required)

Pet's Name

Pet allergies or pre-existing conditions

Length of ear from base of skull to tip of ear measuring from furry side and not the fleshy side of the ear. Please be precise.(Required)

Break or Fold location on the ear (base of skull, midway, near tip?)

What created the break in pet's ear?(Required)

Breed of pet(Required)

Age of pet(Required)

City(Required)

State (If willing to travel please indicate what state(s).)(Required)

Zip Code(Required)

Two head shot pics of your pet's ear(s) (Minimum of two head shot pics required)(Required)

Drop files here or

Max. file size: 10 MB, Max. files: 4.

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