Rescue Intake Form ANIMAL INFORMATION Pet Name * ORGANIZATION DETAILS Name Of Organization Responsible For This Animal * Registered Charity Number * Address Line 1 * Address Line 2 City/Town * Province * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code * Case Worker Name * Phone Number * (###) ### #### EMAIL * Foster Or Caregiver's Name * Phone Number * (###) ### #### EMAIL * AUTHORIZED DECISION-MAKER DETAILS Name Of Person Aurthorized To Make Decisions * Phone Number * (###) ### #### If The Authorized Decision-Maker Is Not Present At The Appointment, They Must Be Available By Phone At The Time Of The Visit To Provide Consent and Make Decisions. * PLEASE CONFIRM YOU UNDERSTAND THIS REQUIREMENT I UNDERSTAND Payment Agreement PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED * PLEASE CONFIRM YOU UNDERSTAND THIS REQUIREMENT I UNDERSTAND HOW WILL PAYMENT BE MADE? * While cheques are accepted for rescues, credit/debit or cash are preferred. CREDIT CARD DEBIT CARD CASH CHEQUE Your form has been successfully submitted! Thank you for providing this important information. If any additional details or clarifications are needed, a member of our dedicated team will be in touch with you directly.
