Authorization Form for Rescue Organizations

Authorization Form for Rescue Organizations
Rescue Information
Rescue Organization
Other Rescue Names
Rescue Point of Contact Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Patient Information
Pet Name*
Species*

CanineFeline
Sex*

Female - SpayedFemale - UnspayedMale - NeuteredMale - Unneutered
Date of Birth*

MonthDayYear
Date
Breed*
Color*
Current Medications*
Rescue Authorization
I, Rescue Name* , authorize Foster Name* to bring in Pet Name* under my account and authorize any of the following services for this patient:

Please authorize any of the following services for the patient under your organization *

	Accept	Decline
Full Vaccines
Vaccines - Rabies Only
Heartworm Test (Dogs Only)
Combo FIV / FELV Test (Cats Only)
Heartworm Preventions
Flea / Tick Preventions
Radiographs
Ultrasound
Bloodwork
Medications(Antibiotics / Pain / Etc)
Surgery / Anesthesia
Euthanasia
Cremation - Private
Cremation - Communal

Approved Quantity for Heartworm and/or Flea/Tick Preventions (Number of Doses)*
Billing
I understand that payment must be rendered at the time of service for each patient BEFORE the patient/foster leaves the building, and state that the financial obligation for the approved services falls under:*

Rescue OrganizationFoster / Client Bringing in Patient
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Rescue Information