MicroChip ID Online Activation

You will need your pet's microchip number and a credit card. (Cost is $19.75)

1) Fill in your contact and pet information below.
2) Note: Please CHECK for ACCURACY before submitting!
3) Confirmation will be mailed with your free gift.
(You may also print and fax (or mail) your activation with payment)

MICROCHIP REGISTRATION FORM

Owner's Information
Last Name: (required)	First Name: (required)	Middle Initial:
Mailing Address: (required)
City: (required)	State: (required)	Zip: (required)
Home Phone: (required)	Work Phone:	Cell Phone:
Email Address: (required)

Alternate Contact
Last Name:	First Name:	Middle Initial:
Address:
City:	State:	Zip:
Home Phone:	Work Phone:	Cell Phone:
Email Address:

Veterinarian or Implanter
Last Name:	First Name:	Middle Initial:
Facility:
Address:
City:	State:	Zip:
Phone:	Email Address:

Pet Information
Name:	Species: (required)	Breed:
Date of Birth	Gender: (required)	Neuter/Spay:
Color/markings: (required)
Microchip ID Number: (required)	Provider Code: (if available)

Acceptance:
Signature: By entering my name in the box below I testify that the information contained herein is true and correct. My signature authorizes the release of this information in the best interests of the pet. (required)
Terms and Conditions:
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Agree (I have read, understand, and agree to the terms and conditions of use.) (required)

Locate your pet's microchip number on the
back of your Activation Card. See
Note: If you do not have an Activation Card,
please have your pet's chip number ready.

Business office hours
9-5 CST Monday - Friday
Phone: (800) 434-2843
Fax: (985) 796-1531

Email: answers@microchipidsystems.com

Microchip ID Systems, Inc.
Activation Department
81447 Highway 25
Folsom, LA 70437