Rescue Organization Pre-Appointment Approval Form

Rescue Organization Pre-Appointment Approval Form
Please fill out the form as accurate as possible. This will help us prepare and assess the pet correctly.

IF THIS FORM IS NOT COMPLETED PRIOR TO THE PET'S SCHEDULED APPOINTMENT, WE RESERVE THE RIGHT TO CANCEL THE APPOINTMENT.
Rescue Information
Rescue Name*

First NameLast Name
Rescue Phone Number*
Please enter a valid phone number.
Rescue Email*
example@example.com
Rescue Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Point of Contact for Payment and Authorization of Services/Treatments*
Would you like to add a payment card on file?*

Yes (Preferred Method. Please contact the clinic with the card information)No (You must be available at the end of the appointment to provide payment)
Is the rescue 501(c)(3)?

Yes (Will need to upload at the bottom of this form for tax exemption)No
Pet Information
Pet's Name*
Species (dog, cat)*
Breed*
Age*
Please indicate weeks, months or years
Gender*
Type of visit requested*

Preventative Wellness: $40 examination fee; with a minimum of $50 in preventative health care, the wellness examination fee is waivedMedical Consultation/Sick Appt: $50 examination feePreventative Wellness and Medical Consultation Combination: $50 examination feeTechnician Appointment: $5 fee (only applicable for pet's already established at Pawsitive Care; i.e. booster vaccinations, Toe Nail Trims, etc)
Reasons/Concerns for Visit*
If there are no concerns, please put 'None'

Please answer the following items and see if your pet is experiencing the following symptoms:*

	Yes	No	Remarks / Notes
Coughing
Sneezing
Nasal discharge
Ear odor/head shaking/ear infection
Vomiting
Diarrhea
Increased Urination
Increased Water Consumption
Lethargic (weakness)
Limping
Painful
Change in Appetite

What are the medications, supplements and/or vitamins the pet is receiving?
Which of the following vaccines and diagnostics are approved for this pet? (Select all that apply) *For all pets over 16 weeks of age, a current Rabies Vaccine is REQUIRED for the pet to be seen at our Clinic (proof required). If the pet does not have a valid rabies vaccine, please select Rabies vaccination from the list below.*

DHPP (Canine Distemper, Hepatitis, Parainfluenza and Parvovirus)RabiesLeptospirosisBordetellaH3N2+8 (Canine Influenza)LymeHeartworm TestHeartworm and Tick-borne panel TestHeartworm PreventionFlea and Tick PreventionComprehensive Bloodwork Panel (CBC & Chemistry, starting at $75)FVRCP (Feline Distemper)FeLV (Feline Leukemia)Triple Test (FIV, FeLV and Heartworm)Toe Nail Trim ($10 feline, $20 canine)Microchip $35 (Comes with lifetime registration)Microchip Implantation ($15 -Microchip must be provided by Rescue)
What is the first and last name of the person bringing the Pet to this appointment?*
What is the phone number for the person bringing the Pet to this appointment?*
What is the email address for the person who will be bringing the pet to the appointment and/or fostering the pet?
Upload any and all related documents here (previous records, vaccination certificate, pictures, etc.)

Cancelof
Consent
Pet Owner/Representative of the Rescue Organization Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

Rescue Information