Rescue Intake Form Animal Information NAME OF PET * Organization Details NAME OF ORGANIZATION RESPONSIBLE FOR THIS ANIMAL * REGISTERED CHARITY NUMBER * ADDRESS LINE 1 * ADDRESS LINE 2 CITY/TOWN * POSTAL CODE * PROVINCE * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon CASE WORKER NAME * PHONE NUMBER * (###) ### #### EMAIL * FOSTER OR CARE GIVER'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? * CREDIT CARD Option 2 Option 3 Option 4 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.
