RESCUE SURGERY/DENTAL Authorization Form

RESCUE AUTHORIZATION SURGERY/DENTAL APPOINTMENT - YOU MUST BE A RESCUE TO FILL THIS OUT (not a foster)
WE REQUIRE AT LEAST 2 WEEKS FROM BEING PULLED FROM A SHELTER WITH NO SIGNS OF AN UPPER RESPIRATORY INFECTION, NO EXCEPTIONS.
Rescue Name:*
Foster's Name and Number*
Contact for medical approvals - please be available*
A person authorized to make medical decisions
EMAIL FOR INVOICE/MEDICAL RECORDS? YOU WILL ALSO GET A COPY OF THIS AUTHORIZATION:
example@example.com
Species*
Pets Name:*
Pet's Age:
If you don't know, leave blank we will estimate
Gender*
Surgery Authorization*

DOG SPAYDOG NEUTERFELIINE SPAYFELINE NEUTERDentalOrthopedic SurgerySoft TissueOther
Surgery Add-Ons*

No add-onsTattoo ($7)24hr injection24hr injection >31lbs ($24)IV Fluids ($10)E-Collar ($10)In-Stock Microchip ($20)Rescue Microchip ($5)Other
What is the orthopedic/soft tissue surgery and what limb (if applicable)
Any known medical concerns?

Heartworm POSITIVEUnknownNoneOther
Any known medical concerns?

Feline HerpesvirusFeline Panleukopenia Virus (FPV)Feline Immunodeficiency Virus (FIV)Feline Infectious Peritonitis (FIP)Feline Leukemia Virus (FeLV)Feline Calicivirus (FCV)UnknownNoneOther
Canine vaccinations: I authorize:*

DHPP (canine)Bordetella (canine)Rabies (canine)Leptospirosis (canine)No vaccinations at this timeCanine InfluenzaOther
Feline vaccinations: I authorize:*

Rabies PureVax - see belowRabies - see belowFVRCP (feline)FeLV (feline)No vaccinations at this timeOther
Canine Test: I authorize:*

Heartworm test ($28)4Dx (heartworm+tick disease) ($32)Fecal flotation ($14)Giardia Snap Test ($24)Ear Cytology ($28)Skin Scrape ($28)Ringworm Screening ($13)IOP (intraocular pressure) ($24)In-house urinalysis ($28)Ear Cytology ($28)No tests at this timeOther
Feline Tests: I authorize:*

Feline Triple Test ($28)Fecal flotation ($14)Ear Cytology ($28)Skin Scrape ($28)Ringworm Screening ($13)IOP (intraocular pressure) ($24)In-house urinalysis ($28)No tests at this timeOther
What services are you authorizing

Nail trim ($7-$15)Anal Gland Expression ($15)In-Stock Microchip ($20)Rescue Microchip (you provide) ($5)Ear Cleaning ($15)No services at this timeOther
What else are you authorizing?
I authorize an ear cytology IF there is a concern for infection during the exam*

YesNo
If positive for an infection, do you authorize medication*

YesNo
Dewormer:*

Yes, dispense a dewormer IF fecal float is POSITIVE - only send one round homeNegative Fecal Float - STILL send home a dewormerYes, dispense a dewormer IF fecal float is POSITIVE - send two rounds homeDo NOT dispense a dewormerOther
If a heartworm test was authorized & your foster pet is POSITIVE for heartworms*

Do NOT dispense any productsDispense 30 days of DoxyPet is under 7 months old - too youngPrednisone and Gabapentin for the morning of 1st injection, only ($3/each)Other
Please send the following home with the foster, if requesting more than one, add quantity in "other" field

Simparica TRIOHeartgard3 week coverage Bravecto12 week coverage BracectoSenergy (cats)Other
Do you authorize any of the following:
Do you authorize any additional services and/or medications?
Is this Pet*
You selected "this pet is adopted" any special instructions?
Please remind your foster parent:
- Stop food after 9:30pm the evening before, little water is okay until drop-off
- Drop-off between 7:30am-8:00am on Wednesday - pickup 4:30pm
- Drop-off between 7:30am-8:00am on Tuesday - pickup 4:30pm
- Drop-off at 8:00am on Friday - pickup 4:30pm-8:00pm
- Let their foster pet use the restroom BEFORE being dropped off. All pets are given the opportunity to use the restroom, but some do choose not to while in our care. We are unable to bathe their foster pet should they have an accident in their cage
- DO NOT be late to drop off or pickup
- All dogs need to have a leash/collar and cats must be in a carrier
UPLOAD MEDICAL DOCUMENTS HERE

UPLOAD ANY MEDICAL FILES, VACCINATIONS, RADIOGRAPHS, LABWORK, ETC
Cancelof
I approve CHEW to take pictures of our foster pet and post on social media

I agree
Choose one of the following:*

I REQUEST the use of life saving measures, such as medications or CPR (Resuscitation), if my pet suffers complications during anesthesia, including respiratory or cardiac arrest. I understand that my pet may not respond to medications or CPR, or that he/she may respond initially and then suffer another arrest later. I understand that my pet may die despite our live saving measures, and that if he/she survives, there may be permanent complications. I acknowledge and understand that I will be financially responsible for any professional fees related to these emergency treatments. I will NOT hold the team at CHEW Animal Clinic responsible for the passing of my pet in the event of an emergencyI DECLINE the use of life saving measuring, including medications or CPR (Resuscitation), if my pet suffers complications during anesthesia, including respiratory or cardiac arrest. I understand that my pet may die without the use of life saving measures. I elect to have DNR (Do Not Resuscitate) orders placed on my pet’s record. I will NOT hold the team at CHEW Animal Clinic responsible for the passing of my pet in the event of an emergency
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RESCUE AUTHORIZATION SURGERY/DENTAL APPOINTMENT - YOU MUST BE A RESCUE TO FILL THIS OUT (not a foster)