RESCUE WELLNESS/SICK Authorization Form

RESCUE SICK AUTHORIZATION - YOU MUST BE A RESCUE TO FILL THIS OUT (not a foster)
Rescue Name:*
EMAIL FOR INVOICE/MEDICAL RECORDS? YOU WILL ALSO GET A COPY OF THIS AUTHORIZATION:
example@example.com
Pets Name:*
Best contact for medical authorization **PLEASE BE AVAILABLE***
Number
Pet's Age:
If you don't know, leave blank we will estimate
Gender*
Species*
PLEASE READ

DUE TO THE DELAYED RESPONSE TIME ON APPROVALS, WE ARE ASKING RESCUES TO PRE-APPROVE DIAGNOSTICS and/or TREATMENT. PLEASE USE THE REFERENCE TOOL BELOW TO TO GUIDE YOUR APPROVALS.

IF YOUR PET IS HAVING - APPROVE:

DIARRHEA: fecal flotation, dewormer, antibiotic, probiotic

CHRONIC DIARRHEA: fecal flotation, parvo test, bloodwork, dewormer, antibiotic, dewormer

VOMITING: bloodwork, fecal flotation, cerenia, famotidine

DIARRHEA/VOMITING: bloodwork, x-rays - treatment plan will be based on findings

LOSS OF APPETITE: bloodwork, x-rays - treatment plan will be based on findings

COUGHING: antibiotics (coughing tabs, if needed)

CHRONIC COUGHING/NASAL/OCULAR DISCHARGE: bloodwork, xrays, antibiotics, coughing tabs.

LIMPING/HOPPING/OTHER ORTHOPEDIC: x-rays, anti-inflammatory, pain medication (trazodone, as needed)

ONE OR MORE ABOVE: if your pet is having one or more symptoms above, please approve appropriately.

PLEASE NOTE: CHEW Veterinarians will not do any diagnostics/treatment unless it is absolutely necessary. Approving these services does not necessarily mean they will be preformed, and we always keep cost/resources in mind.

We appreciate you pre-approving so we can stay on schedule
Canine Test: I authorize:*

Heartworm test ($28)4Dx (heartworm+tick disease) ($32)Fecal flotation ($14)Giardia Snap Test ($24)Parvo Test ($38)Ear Cytology ($28)Skin Scrape ($28)Woods Lamp/ringworm ($13)IOP (intraocular pressure) ($24)Distemper Test ($220)In-house urinalysis ($28)Idexx Urinalysis ($57.65)Radiographs ($84)Fastscan ultrasound ($40)Radiographs ($88.20)Nothing at this timeOther
Feline Tests: I authorize:*

Feline Triple Test ($28)Fecal flotation ($14)Ear Cytology ($28)Skin Scrape ($28)Woods Lamp/Ringworm ($13)IOP (intraocular pressure) ($24)In-house urinalysis ($28)Idexx Urinalysis ($57.65)Radiographs ($88.20)Nothing at this timeOther
Do you authorize us to dispense medication (if needed)?
Has this pet been seen by another vet about this illness/injury? If yes, please upload medical records (or bring a copy for us to keep)
UPLOAD MEDICAL DOCUMENTS HERE

UPLOAD ANY MEDICAL FILES, VACCINATIONS, RADIOGRAPHS, LABWORK, ETC
Cancelof
If Pet is healthy to get vaccinations, I authorize?*

DHPP (canine)Bordetella (canine)Rabies (canine/feline)Leptospirosis (canine)No vaccinations at this timeOther
If Pet is healthy to get vaccinations, I authorize?*

Rabies PureVax - see belowRabies - see belowFVRCP (feline)FeLV (feline)No vaccinations at this timeOther
What are the clinical signs this pet experiencing? Please be detailed; when did these symptoms start, are they getting worse, etc
Example: vomiting, bloody diarrhea, limping, lethargic, etc
I approve CHEW to take pictures of our foster pet and post on social media

I agree
Should be Empty:

RESCUE SICK AUTHORIZATION - YOU MUST BE A RESCUE TO FILL THIS OUT (not a foster)