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 (not to be used for authorization):*
Foster's number (NOT to use for medical approvals)
Please enter a valid phone 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
Pets Name:*
Pet's Age:
If you don't know, leave blank we will estimate
Is this Pet*
Gender*
Species*
Does this pet have heartworms (dog) or FIV (cats)
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)Parvo Test ($28)Distemper Test ($220)Ear Cytology ($28)Skin Scrape ($28)Ringworm Screening ($13)IOP (intraocular pressure) ($24)In-house urinalysis ($28)No tests at this timeOther
Feline Tests: I authorize:*

Feline Triple Test ($28)Fecal flotation ($14)Ear Cytology ($30)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
I authorize a dewormer IF there are parasites found in the fecal flotation*

Yes, dispense a dewormerDo NOT dispense a dewormerN/A, I did not approve a fecal testOther
If a heartworm test was authorized & your foster pet is POSITIVE for heartworms*

Dispense 2 iverhartDo NOT dispense any productsDispense 30 days of DoxyPet is under 6 months oldOther
Do you authorize any of the following:
I authorize the following to be sent home with the foster

1 Simparica Trio (heartworms/flea/tick)6 Iverhart (heartworms only)2 Simparica Trio (heartworms/flea/tick)1 mth Bravecto (flea/tick only)6 Simparica Trio (heartworms/flea/tick)2 mth Bravecto (flea/tick only)1 Iverhart (heartworms only)6 mth Bravecto (flea/tick only)2 Iverhart (heartworms only)None at this timeOther
Do you authorize any additional services and/or medications?
You selected "this pet is adopted" any special instructions?
SURGERY/DENTAL
Surgery Authorization

DOG SPAY 3lbs - 30lbsDOG SPAY 31lbs - 69lbsDOG SPAY 70lbs - 95lbsDOG SPAY 96lbs and aboveDOG NEUTER 3lbs - 30lbsDOG NEUTER 31bs - 69lbsDOG NEUTER 70lbs - 95lbsDOG NEUTER 96lbs and aboveFELIINE SPAYFELINE NEUTERDentalOrthopedic SurgeryOther
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
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 - pickup between 4:00pm-4:30pm
- 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)