Veternarian Request Form

Owner Information

We need a little information about you to help us better fit your needs. Please complete the form to the best of your ability. The more information we have, the better we can help you and your pet.

Today's Date

Name *

First

Last

Email *

Phone *

Best contact number to reach you in case of emergency

Mailing Address

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Current Living Accomodations *

• Unhoused (Street, Car, Park etc)
• Emergency Shelter
• Transitional Housing
• Other

If you chose other please explain

Pet Information

Now we need a little information about your pet. Nothing is a deal breaker so please be as honest as you can about your pet.

Name of Pet #1 *

Type of Pet *

• Dog
• Reptile
• Cat
• Small Critters (hamsters, guinea pigs etc)
• Bird
• Other

Sex of pet *

• Male
• Female

Pet Age

Breed/Color/Markings on pet *

Has your pet been spayed/neutered? *

• Yes
• No

Name of Pet #2

Type of Pet

• Dog
• Reptile
• Cat
• Small Critters (hamsters, guinea pigs etc)
• Bird
• Other

Pet #2 Gender

• Male
• Female

Pet #2 Age

Breed/Color/Markings on pet:

Why does your pet need to be seen by a vet? *

Veterinarian Clinic Name *

If you do not have a vet, please put “none” in the field. We use this to verify shot records in the event we need to board your pet with other pets in the home.

Veterinarian Address

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

If you don’t know the exact address please put the cross streets of its location. (ie.. 72nd & Doge St.)

Does your pet(s) have previous illness or health issues we should know about? *

If so, please explain

Do any of the following apply to your pet(s)?

• Allergies
• Dietary Restrictions
• Requires Medication

Current Vaccinations of your pet(s), please check all that apply: *

• Parvovirus
• Distemper
• Parainfluenza Hepatitis
• Rabies
• Leptospirosis
• Bortadella
• Unsure/Not Vaccinated

If you are unsure please make sure your vet information is up to date so we can verify vaccinations.

Terms & Conditions

• I have read and understand the terms of contract and the terms are agreeable to me. It is understood and agreed that the terms of this vet request agreement shall be in effect for any subsequent vet visits of my pet.
• I certify this I am the legal owner of the pet.

Signature

By inputting your name above, you agree the form is filled out to the best of your knowledge. Any false information given will void any agreements made between you and Together Furever.

Date

Submit

THIS AGREEMENT is entered into between the undersigned owner of the pet and Together Furever Nonprofit. Terms and conditions are as follows: 

1. The owner hereby warrants and assures Together Furever, its staff/volunteers, and guests that the pet is free of any disease and is not currently under any veterinarian treatment except as disclosed in writing on this contract.

2. Unless the owner provides in writing to Together Furever, the pet will be released only to the undersigned owner. 

3. The owner agrees that if the pet becomes ill or otherwise requires professional veterinarian attention, that Together Furever may engage in services of a veterinarian or other qualified professional to provide needed medical services for the pet.

4. Together Furever may use you for advertising, fundraising and other purposes to further the mission.  

5. The owner agrees to release all diagnostic information regarding veterinarian care of pet.

6.  Together Furever is obligated to report any signs of abuse to pets upon intake interview.