RESCUE WELLNESS AUTH - To be filled out by rescue, not foster
This Pet is:
Please Select
Adopted - no longer under the rescue
Still under the care of the rescue
Rescue Name:
*
Foster/Adopter 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 ($17.40)
Rabies - see below ($12.80)
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:
Above, you noted this pet is adopted. Please select all that apply:
Rescue to pay for all products and services on this form
Adopter to pay for all products and services on this form
Adopter to pay for any requested products and services
Other
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: