RESCUE WELLNESS AUTH - To be filled out by rescue, not foster
This Pet is:
Please Select
In foster care
Adopted
Adopted Pet – Rescue Instructions for CHEW:(Include details such as financial responsibilities, approved records for release, etc.)
Rescue Name:
*
Foster's Name and Number:
*
Contact for medical approvals - please be available
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Pet's Age:
If you don't know, leave blank we will estimate
Gender
*
Please Select
Female
Male
Spayed Female
Neutered Male
Unknown
Species
*
Please Select
Canine
Feline
Canine vaccinations: I authorize:
*
DHPP (canine)
Bordetella (canine)
Rabies (canine/feline)
Leptospirosis (canine)
No vaccinations at this time
Canine Influenza
Other
Feline vaccinations: I authorize:
*
Rabies - PureVax - see below
Rabies - see below
FVRCP (feline)
FeLV (feline)
No vaccinations at this time
Other
Canine Test: I authorize:
*
Heartworm test
4Dx (heartworm+tick disease)
Fecal flotation
Giardia Snap Test
Parvo Test
Distemper Test
Ear Cytology
Skin Scrape
Ringworm Screening
IOP (intraocular pressure)
In-house urinalysis
Nothing at this time
Other
Feline Tests: I authorize:
*
Feline Triple Test
Fecal flotation
Ear Cytology
Skin Scrape
Ringworm Screening
IOP (intraocular pressure)
In-house urinalysis
Nothing at this time
Other
What services are you authorizing
Nail trim
Anal Gland Expression
In-Stock Microchip
Rescue Microchip (you provide)
Ear Cleaning
Other
What else are you authorizing?
I authorize an ear cytology (only if there is a concern for infection during the exam)
*
Yes
No
If positive for an infection, do you authorize medication
*
Yes
No
Dewormer:
*
Yes, dispense a dewormer IF fecal float is POSITIVE - only send one round home
Do NOT dispense a dewormer
Yes, dispense a dewormer IF fecal float is POSITIVE - send two rounds home
Negative Fecal Float - STILL send home a dewormer
Other
If a heartworm test was authorized & your foster pet is POSITIVE for heartworms
*
Do NOT dispense any products
Dispense 30 days of Doxy
Pet is under 7 months old - too young
Prednisone and Gabapentin for the morning of 1st injection, only ($3/each)
Other
Do you authorize any of the following:
Please send the following home with the foster, if requesting more than one, add quantity in "other" field
Simparica TRIO
3 week coverage, Bravecto
Heartgard
12 week coverage, Bravecto
Senergy (cats)
Other
Do you authorize any additional services and/or medications?
List any medical concerns you have about this pet:
UPLOAD MEDICAL DOCUMENTS HERE
Browse Files
Drag and drop files here
Choose a file
UPLOAD ANY MEDICAL FILES, VACCINATIONS, RADIOGRAPHS, LABWORK, ETC
Cancel
of
I approve CHEW to take pictures of our foster pet and post on social media
I agree
Submit
Should be Empty: