Patient Admission Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Rescue Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Rescue (When the animal was initially found)
*
-
Month
-
Day
Year
Date
What species did you rescue? (ex. squirrel, fox, skunk, raccoon, etc.)
*
Number of animals rescued (ex. 5 baby squirrels)
*
Reason for Rescue
*
Did the animal bite any people or pets?
*
Please Select
Yes
No
Unsure
Did you provide any care such as food, water, or wound care?
*
Donations: Wilderness Way Wildlife rehabilitates and cares for orphaned, ill, injured, and displaced wildlife until they can thrive in their native habitat. We are a 501(c)(3) non-profit organization and receive no financial aid from the government or any other agency. Donations go directly to animal care to help us provide food, supplies, medications, and veterinary care. Any help is greatly appreciated!
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