Clinic/Services Request Form

Please use this request form to send us a request for service. Complete one registration form for each pet (you can combine puppies/kittens from the same litter on the same request form if you wish). Someone at Leech Lake Legacy will contact you to confirm the details of your request.

First Name
Last Name
Home Phone #
Mobile Phone #
Email
Mailing Address
Street Address
City
State
Zip
Do you live on the Leech Lake Reservation?
Are you a Leech Lake band member?
Pet Name
Pet Species (cat, dog, etc.)
Pet Breed
Pet Age
Pet Color/Markings
Is your pet spayed or neutered?
Pet Gender (Male or Female)
Has your pet had any litters? If so, how many and when?
Pet Weight
Has your pet previously received vaccines?
If previously vaccinated, what did they receive and when?
Did Leech Lake Legacy provide the vaccines?
Pet Description & Health Concerns
Which services are you interested in? (Check all that apply)
- Spay/Neuter (includes wellness)
- Wellness only
- Surrender
Services through Leech Lake Legacy are for residents of the Leech Lake Reservation or enrolled band members only. Due to high demand, our waitlist is currently quite long, it will take several months to get a call for an appointment.