Shipping Address:

Name:

Address:

City, State, Zip:

Day Phone:

Eve Phone:

Billing Address (if different from above):

Name:

Address:

City, State, Zip:

Day Phone:

Eve Phone:

Wheelchair prices: Determined by accurate weight of dog. Products shipped via UPS (listed below), or USPS Priority Mail by request.

Weight	Price	3-Day Select	Ground
3-9	$225	$38	$18
10-19	$260	$42	$22
20-39	$295	$48	$27
40-59	$335	$55	$32
60-79	$375	$60	$36
80-99	$395	$65	$40
100+	$430	$75	$45

There is a three week trial period for your dog to adjust to the wheelchair. If for any reason you return the wheelchair, I will refund 65% of the cost of the wheelchair (not including shipping).

Cost		Method of Payment
Wheelchair	$	___ Certified Check / Money Order
Other Booties, etc.	$	___ American Express
Shipping & Handling	$	___ MasterCard
COD add $7	$	___ Discover
Total	$	___ Visa
		___ COD

Card #:	Exp. Date:
Signature:	Print Name:

About Your Dog:

Dog's Name:

Breed:

Age:

Weight:

Sex:

If mixed breed, please describe:

Cause of Disability:

Date/Onset of Disability:

Surgery?	When?
Any use of rear legs?	Strong front legs?
Activity level: Very active / Moderately active / Inactive	Is your dog: Indoor / Outdoor / Both

Type of terrain dog will be using wheelchair on:

Dog's favorite activities:

Comments:

Tips for taking accurate measurements (in inches): It is important that the measurements are as accurate as possible. Have someone assist you. If your dog cannot stand, lay your dog on his/her side. Use straight lines, as in the diagram, except for #4, #5 & #8 (these are girth measurements). For #1, #2 & #3 what I'm looking for is where the leg attaches to the body, the pivot point or where the joint is located. For #6 & #7, what I'm looking for here is how wide is your dog at the shoulder or hips. Use straight lines and DO NOT follow the curvature of back. Girth of #5 is where one leg attaches to the body, like your putting a pair of pants on dog what would be the circumference of the leg hole. Any questions? Please call.

1. Center of hip to floor:	5. Girth of upper thigh:
2. Center of shoulder to floor:	6. Width of hips:
3. Center of shoulder to center of hip:	7. Width of shoulders:
4. Girth of chest behind the front legs:	8. Girth of abdomen: