Ruff Haven Urgent Care Referral Form
To be completed by a case manager or service provider for clients in need of urgent pet care. This is a one-time assistance program with limited availability.
Case Manager Information
Case Manager Name
*
Email
*
example@example.com
Phone Number
*
Organization
*
Pet Owner Information
Pet Owner Name
*
Phone Number
*
Email
example@example.com
Client Housing Status
*
Please Select
Unsheltered
Emergency Shelter (Homeless Resource Center, etc)
Transitional Housing
Permanent Supportive Housing
Other
Housing Status if Other
Pet Information
Pet Name
*
Species
*
Please Select
Dog
Cat
Other (Please specify)
Species if Other
Describe the urgent medical issue
*
Additional Information
Is the client able to transport the pet?
*
Yes
No
Maybe
Any other information we should know?
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: