Vetama Ambulance Request
Your request will be reviewed an you will be contacted as soon as possible. Payment is due at time of service. Call (702)292-0972 with questions.
Requesting Client Information
Name
*
First Name
Last Name
Name
*
Full Name
Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Patient Information
Patient Name
First Name
Last Name
Patient Species
*
Canine
Feline
Patient Breed
*
Patient Weight (lbs)
*
Case Information
Reason for Transport
*
Emergency transport
Routine transport
Interhospital transfer - critical
Interhospital transfer - routine
Other
Pickup Date/Time
*
Pickup Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Drop Off Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Receiving Contact Name
*
First Name
Last Name
Receiving Contact Phone
*
Please enter a valid phone number.
In case of emergency:
*
DNR - Do Not Resuscitate. We will not intervene with natural course of death
CPR - Cardiopulmonary Resuscitation. We will take all means necessary to preserve the animal's life.
Signature
*
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Vetama Ambulance Dispatch
Non-member
$
250.00
Quantity
1
2
3
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5
6
7
8
9
10
Credit Card
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