Skip to content
(801) 805-4800
7211 Plaza Center Dr, #160 West Jordan, UT 84084
Puppies for Sale
Puppy Quiz
Puppy Payments
Food & Supplies
Benefits
Blog
Info
About Us
12-Year Guarantee
FAQ
File A Claim
Careers
Contact Us
Puppies for Sale
Puppy Quiz
Puppy Payments
Food & Supplies
Benefits
Blog
Info
About Us
12-Year Guarantee
FAQ
File A Claim
Careers
Contact Us
Owner Information
Name
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
Phone
(Required)
Purchase Details
Location of Purchase
(Required)
Las Vegas
Henderson
St. George
Salt Lake
Vineyard
Other
Other Location
You selected "Other" for the Location of Purchase. Which location did you purchase from?
Date of Purchase
(Required)
MM slash DD slash YYYY
Invoice / Contract Number (if known)
Puppy Details
Puppy Name
(Required)
Puppy Breed
(Required)
Puppy Sex
(Required)
Male
Female
Puppy Date of Birth
MM slash DD slash YYYY
Microchip Number
(Required)
AKC or Registration Number
Illness Timeline
First Symptoms Date
(Required)
MM slash DD slash YYYY
First Vet Visit Date
(Required)
MM slash DD slash YYYY
Most Recent Vet Visit Date
MM slash DD slash YYYY
First Symptoms (describe)
(Required)
Was the puppy hospitalized?
(Required)
Yes
No
How long was the puppy hospitalized?
Vet / Clinic Info
Primary Vet
(Required)
Vet Phone
(Required)
Vet Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
OK to contact your veterinarian and share records?
(Required)
I authorize the store to contact my vet and review records for this claim.
Diagnosis & Test Results
Diagnosis Type
(Required)
Viral
Bacterial
Parasitic
Hereditary
Congenital
Accidental
Unknown
Other
If “Other,” diagnosis
Diagnosis Name (if given)
Tests Performed (check all)
Parvo ELISA
Distemper PCR
Fecal Float
Fecal PCR
Giardia Test
CBC
Chemistry Panel
Urinalysis
Radiographs (X-rays)
Ultrasound
Culture & Sensitivity
Other
If “Other test,” name
Positive/Negative Results
Treatments & Medications
Services Provided
Medications Given
Was the puppy insured?
Yes
No
If insured, claim #
Itemized Costs
Itemized Vet Charges
(Required)
Date (MM/DD/YYYY)
Provider/Clinic
Service/Description
Amount (USD)
Add
Remove
Medications Purchased
Date (MM/DD/YYYY)
Medication Name
Qty/Days
Amount (USD)
Add
Remove
Other Related Costs
Date (MM/DD/YYYY)
Description
Amount (USD)
Add
Remove
Total Claimed Amount
Proof & Attachments
Upload Documents
Please upload any of the following documents: Invoice, contract, vet records, itemized bills, test results, photos. Only certain files are accepted.
Drop files here or
Select files
Accepted file types: jpg, png, pdf, Max. file size: 20 MB.
Declarations
Was the puppy showing signs of illness at the time of purchase?
Yes
No
Unsure
Did you notify the store within the required time after symptoms began?
Yes
No
Comment / Concern
Agreements
(Required)
I certify the information is true and accurate. I understand false or incomplete info may delay or deny the claim.
I understand that submission does not guarantee reimbursement.
Signature
Please type your First and Last Name to certify your agreement and form submission.
