Rescue Group *

Main Contact (Authorized for pet's healthcare decisions) *

First

Last

Foster Contact

First

Last

Rescue Contact Phone *

Foster Contact Phone

Rescue Email *

Foster Email

Pet's Name *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Species *

Dog
Cat

Age/Date of Birth (if known) *

Breed *

Color *

Please list any medical conditions, allergens, previous surgeries, or other known vital information regarding this pet. If you have nothing to add, please put "none" in this section. *

Please list any medications or supplements that this pet is currently given and for how long. If you have nothing to add, please put "none" in this section. *

Date of pet's appointment *

Who should we contact day of appointment? *

May we text you instructions, updates, etc. at this number? *

Yes
No

What city and state is the pet from? *

By the time of scheduled appointment, how long will the pet have been in Colorado? *

Is the pet displaying any signs of illness? *

(including but not limited to vomiting, diarrhea, coughing, sneezing, lethary, or loss of appetite.)

Animal Works Veterinary Surgery requires a Pre-Anesthetic Profile for all pets 5 years of age or older. Pre-Anesthetic Profile checks the pet's organ functions to see if we need to alter our anesthetic protocol or medications to go home. If the pet has recently had blood work performed at another clinic, please upload with other records. The cost for Pre-Anesthetic Profile for rescue groups is $96 *

Pre-Anesthetic Profile (0-4 Years, always recommended but optional) $96
Pre-Anesthetic Profile (5+ Years, required) $96
I decline Pre-Anesthetic Profile for this pet that is under 5 years of age
The pet has recently had blood work performed at Animal Works or another clinic within the last 6 months

Intravenous Catheter Placement & Fluid administration during surgery/recovery: While not mandatory in young and healthy animals under 5 years of age, Animal Works Veterinary Surgery recommends Intravenous (IV) fluids administered during surgery to help maintain hydration, normal blood pressure and support the cardiovascular system. The pet will have a shaved area on the front of their leg as the hair must be removed to allow the area to be disinfected properly before inserting the catheter. The fee for intravenous catheter placement, catheter maintenance, and intravenous fluid administration during surgery and recovery for rescue groups is $28 *

IV Fluids (0-5 years, always recommended but optional) $28
IV Fluids (5+ years, required) $28
I decline IV Fluids for the pet that is under 5 years of age

Anti-inflammatory pain medications are recommended to lessen the risk of discomfort and swelling, this will be given as an oral pill, long lasting injection or liquid that you will take home. The fee for postoperative pain management for rescues ranges between $12-$16, depending on the pet's weight. *

Postoperative Pain Medication (based on pet's weight) $12 - $16
I decline postoperative pain medication for this pet
The rescue provides postoperative pain medication

If rescue provides pain management, please list below what will be given *

Please upload referring veterinarian notes, bloodwork, and any other vital records

Click or drag files to this area to upload. You can upload up to 10 files.

Procedure or treatment to be performed: *

**Hold down Shift or Command to select more than one procedure**

Cherry Eye Repair - please specify which eye: *

Entropion - please specify which eye: *

Ectropion - please specify which eye: *

If Other, please specify: *

Other Services requested:

**Hold down Shift or Command to select more than one procedure**

If Other, please specify: *

Additional comments or concerns

Our rescue group has signed a previously provided agreement with Animal Works Veterinary Surgery. We understand that this agreement pertains to each appointment, procedure or surgery with Animal Works Veterinary Surgery and is valid until one of the parties elects to void the contract. We understand that the contract can only become voidable after all services have been rendered and no payment is owed to Animal Works Veterinary Surgery. *

I have read and understand

I certify that I am, in fact, an authorized agent for the rescue group listed above and grant the veterinarians and staff of Animal Works Veterinary Surgery consent and authorization for the above procedure(s) to be performed. The nature of the operation or procedure(s) has been explained to me, and I understand what will be done. I understand that unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above for the safety of the pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional fees for the rescue. I understand Animal Works Veterinary Surgery will use all reasonable precautions against injury, escape, or death of the animal but will not be held liable or responsible in any manner and thoroughly understand that I assume all risks. My signature certifies that I am over 18 years of age. *

I have read and understand

Digital Authorized Agent's Signature *

Date *

Rescue Authorization Form

Please fill out this form as completely as possible.

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