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Home Humane Society Intake Form

Humane Society Intake Form

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Drop off Date

Drop off Time

Human Society/Organization

Authorized Dropoff Person

Other Authorized Person

Phone Number

Animal Name/Number

Have we seen this animal before?

Species

Breed

Comments

Please use DSH, DMH, DLH for short, medium, long hair cats.

Sex

Age/DOB

Color/Markings

Allergies (medication/food)

Current Medications

Temperament/Special Instructions

PLEASE PROVIDE DATES FOR ANY CURRENT VACCINATIONS

Rabies certificates or proof of rabies by a licensed veterinarian is required for it to be considered a previous vaccination.

1st DA2L4PP/1st FVRCPC

2nd DA2L4PP/ 2nd FVRCPC

Annual DA2L4PP/Annual FVRCPC

Bordetella

1st Lymes

Annual Lymes

1st CIV Bi

Annual CIV Bi

1st Feline Leukemia

Annual Leukemia

1st FIP

Annual FIP

Date and Type of Last Flea Treatment

PLEASE SELECT WHICH TREATMENTS YOU WOULD LIKE DONE AT THIS APPOINTMENT.

*Please give a detailed description of the mass and location.

*Would you like a a biopsy done on the area? Yes No

**Please describe the area where we are xraying.

***Please give a description of the amputation.

*Documentation must be provided of a previous Rabies vaccine in order for us to administer a 3 Year Rabies Vaccine.

Required vaccinations for a patient to stay in-clinic are Rabies, DA2L4PP/FVRCPC, Bordetella, CIV Bi(Canines only).

Labratory Presurgical Screen Heartworm Test Fecal Test* Felv Test ( ) FIV Test ( ) HW Test ( ) FIV Test FIP Test Geriatric Profile Thyroid Panel

*Are you providing the stool sample?

Examinations Microchip* Worming Nail Trim

*Microchip Number if providing

Other concerns/problems

If any of the following are seen would you like them treated? Fleas Earmites Worms

Location

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Office Hours

Monday:

07:30 am - 06:00 pm

Tuesday:

07:30 am - 02:00 pm ~~~ 03:00 pm - 06:00 pm

Wednesday:

07:30 am - 06:00 pm

Thursday:

08:00 am - 02:00 pm

Friday:

07:30 am - 06:00 pm

Saturday:

08:00 am - 02:00 pm

Sunday:

Closed

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Testimonials

Reviews By Our Satisfied Clients

"A great place that focuses on the care of an animal. I switched from another place that charges $50.00 for a yearly checkup. Vaccines are paid for and visit is free here. That bring more people in and it serves the community as a whole. Thanks, Westchester Animal Clinic."

Tara D. - Porter, IN