Step 1 of 3 33% CompanyThis field is for validation purposes and should be left unchanged. This form must be completed and submitted prior to the appointment Rescue Organization InformationHas your rescue previously been a client of one of our Specialists before? Yes No Legal Rescue Name First Last Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Upload 501(c)(3)DocumentationMax. file size: 256 MB. 501(c)(3)Documentation IRS Determination Letter AttachedIf not received prior to check-in, the appointment may be rescheduled or services may be provided at standard client pricing. Rescue discounts may not be applied retroactively.Authorized Rescue Point of ContactThe following contacts are authorized to make medical and financial decisions on behalf of the rescueMedical Contact First Last Rescue Position/TitlePhoneEmail Phone Type Cell Home Other Point of Contact Availability During Appointment Available By Phone Present in Person Not Available (Alternate Authorization Required) Financial Contact First Last Rescue Position/TitlePhoneEmail Phone Type Cell Home Other Point of Contact Availability During Appointment Available By Phone Present in Person Not Available (Alternate Authorization Required) We love patient stories!Do we have your permission to share your pet’s image and story on our social media and/or website? Your name and personal information will never be shared, we only use your pet’s first name. Yes No Consent to TreatmentThe Rescue Organization authorizes Salt River Veterinary Specialists to examine, diagnose and treat the patient listed above in accordance with accepted veterinary medical standards. Signature of Rescue Point of Contact or Responsible Agent(Required)Date(Required) MM slash DD slash YYYY Ownership and AuthorityThe Rescue Organization confirms it is the legal owner or lawful custodian of the patient listed above and has full authority to authorize veterinary care and accept financial responsibility.Signature of Rescue Point of Contact or Responsible Agent(Required)Date(Required) MM slash DD slash YYYY Patient and Foster Information Foster InformationFoster Name First Last PhoneEmail Phone Type Cell Home Other Foster Authorization to Consent to Treatment Yes – May authorize routine and emergency care No – May not authorize treatment Limited – May authorize only the following List Add RemoveCommunication including, but not limited to, medical records, treatment updates and invoices may be shared with the foster Yes – Foster May Receive All Communications No – Foster Must Request Information From Rescue Limited – May access only the following List Add RemovePatient InformationPatient’s Name First Last Species Canine Feline Other Sex Male Female Neutered Male Spayed Female BreedColorAge/DOBDiet or brand fedHow often fedWhen last fedAre the patient’s vaccinations up to date? Yes No Year of last rabies vaccinePlease describe the current problem for which the patient is hereList medications being administered (including over-the-counter medications). Please include dosage, frequency, and duration that the medication has been administered to the patientMedicationDosageFrequencyDuration Add RemoveHas the patient had any allergies or drug sensitivities? If yes, please list medications and reactionHas the patient ever had a previous surgery? If yes, please describe brieflyReferring/Primary InformationPrimary ClinicNameDoctorSend Records When Final? (Y/N)Referring ClinicNameDoctorSend Records When Final? (Y/N)Additional Hospitals/ClinicsNameDoctorSend Records When Final? (Y/N)Signature of Rescue Point of Contact or Responsible Agent(Required)Date(Required) MM slash DD slash YYYY Patient Care Practice PoliciesOne of the most important criteria for the delivery of veterinary medical care from veterinarians and staff members at Salt River Veterinary Specialists is an understanding of our patient care practice principals. Please be aware of the following practice policies as a client of Salt River Veterinary Specialists to navigate your pet’s care in collaboration with us: Patient health outcomes are impacted by adherence to the care plan prescribed by our doctors. Compliance with medications, diet, monitoring lab work, and recommended follow-up appointments is an essential part of your pet’s care. It is imperative that there is mutual trust and respect between doctors, staff, and clients. Please maintain a respectful demeanor when communicating your needs and concerns to our staff. Disrespectful and inappropriate temperament will not be tolerated and will be grounds for dismissal from our practice. Our doctors dedicate their daily schedules to in-office appointments. Therefore, they may be unable to answer or return phone calls the same day. Our support staff works diligently with our doctors to address patient concerns as swiftly as possible but please understand same-day answers may not be possible due to emergent patients. Our doctors are unable to review follow-up lab work performed by an outside veterinarian after your initial consultation. We value the expertise of our colleagues and defer to their recommendations if they have ordered lab work for your pet. Recheck appointments are available for additional follow-up questions or concerns regarding lab work performed by an outside veterinarian. Please notify our hospital at least 24 hours in advance of your scheduled appointment should you need to cancel your visit. If an appointment is cancelled without notice, a non-refundable deposit of the exam fee will be required before scheduling future appointments. Salt River Veterinary Specialists is a specialty referral hospital, not an emergency clinic. We are not always able to arrange same-day urgent appointments once we reach capacity. Our doctor may need to refer your pet to an emergency clinic for urgent or emergency care when providing updates by phone regarding your pet’s status. Payment in full is due at the time services are rendered. Should your pet need hospitalization, a prepayment will be required (payments may be made by cash, Visa, Mastercard, American Express, Discover, CareCredit, or Scratchpay). By signing below, you acknowledge you will adhere to Salt River Veterinary Specialists’ Patient Care Practice Policies. Signature of Rescue Point of Contact or Responsible Agent(Required)Date(Required) MM slash DD slash YYYY
