RESCUE WELLNESS AUTHORIZATION - YOU MUST BE A RESCUE TO FILL THIS OUT (not a foster)
Rescue Name:
*
Foster's Name and Number:
*
WANT A COPY OF THIS AUTHORIZATION? PLEASE PROVIDE YOUR EMAIL:
example@example.com
Contact for medical approvals - please be available
Please enter a valid phone number.
Pets Name:
*
Pet's Age:
If you don't know, leave blank we will estimate
Is this Pet
*
Please Select
In Foster Care
Adopted
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 ($25)
4Dx (heartworm+tick disease) ($35)
Fecal flotation ($10)
Giardia Snap Test ($25)
Parvo Test ($25)
Distemper Test ($135)
Ear Cytology ($35)
Skin Scrape ($15)
Ringworm Screening
IOP (intraocular pressure) ($25)
In-house urinalysis ($25)
Nothing at this time
Other
Feline Tests: I authorize:
*
Feline Triple Test ($35)
Fecal flotation ($10)
Ear Cytology ($35)
Skin Scrape ($15)
Ringworm Screening
IOP (intraocular pressure) ($25)
In-house urinalysis ($25)
Nothing at this time
Other
What services are you authorizing
Nail trim ($7-$15)
Anal Gland Expression ($15)
In-Stock Microchip ($20)
Rescue Microchip (you provide) ($5)
Ear Cleaning ($12)
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?
You selected "this pet is adopted" any special instructions?
List any medical concerns you have about this pet:
UPLOAD MEDICAL DOCUMENTS HERE
Browse Files
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UPLOAD ANY MEDICAL FILES, VACCINATIONS, RADIOGRAPHS, LABWORK, ETC
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I approve CHEW to take pictures of our foster pet and post on social media
I agree
Submit
Should be Empty: