Rescue Registration Form
Rescue Information
Name
Rescue
President
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Fax
Please enter a valid fax number.
Other points of contact
Pet Information
Species of animals to be treated
Dog
Cat
Exotic
Records
Please check how you would like records to be sent
Emailed after each visit
Faxed after each visit
Mailed after each visit
Is there any information you would not like printed on the records to go home?
Invoicing
Please indicate the frequency of payment for services
Paid off in full monthly
Charged after each visit with credit card on file
If paid off monthly in full, please choose payment method
Send in check
Charge credit card on file
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Vaccines, Diagnostics, medications & Procedures
Does your rescue cover any of the following vaccines, diagnostics, medications or procedures? If so, please check the appropriate boxes:
Canine Specific
Rabies (1 year)
Dapp
Leptospirosis
Lyme
Bordetella
Influenza (Bivalent)
Blood Parasite Screen (4DX)
Feline Specific
Rabies (1 year)
FVRCP
FIV/FeLV Test
General
Intestinal Parasite Screen
Spay
Neuter
Post Surgical Pain Medication
Pre-Surgical Blood Work *Required for all surgical procedures. If not covered by rescue, adopter will have to pay regular price at time of visit*
Blood Work for Sick Pets
Radiographs
Recommended Medication by Doctor for Sick Pets
Microchipping
If Microchipping, would you prefer
Provide Microchip By Rescue
Use Knoll AH’s (Home Again Microchip)
Are there any diagnostics, procedures, vaccinations, etc not specified that you would like to be contacted about prior to proceeding with recommended treatment? If so, please specify:
Are there any diagnostics, procedures, vaccinations that you absolutely do not cover? If so, please specify:
Additional Questions
Does your rescue offer a discounted or free exam voucher to new adopters?
Yes
No
If yes, please
specify:
blank
valid for
blank
days.
Disclaimer: I am aware that in the event an emergency arises, we may need to reschedule a routine procedure to accommodate an emergency into our schedule.
Please upload 501c3 form
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