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
Format: (000) 000-0000.
Patient Information
Pet Name
Species
Sex
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

Rows	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:
Signature
Date

MonthDayYear
Date
Should be Empty:

Rescue Information