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Rescue Medical Treatment Plan Form
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Email *
Today’s Date *
Full Name of Person Completing Form *
Rescue Organization *
Dogs Name *
Approximate Age (If Known)
Weight Est. (Best Guess)
Sex *
Breed (Best Guess) *
Color *
Health Certificate needed? If yes select which HC needed. Please ensure rabies certificate is emailed to subject Dogs Name Rabies Certificate. We cannot complete without a rabies certificate on file. *
If Health Certificate is Required Please Provide Name & Address for Sender and Receiver (Even if we have filled previous HC for your rescue please fill in)
If Health Certificate is required and 7001 Form Please provide Transporter Name, Phone Number, Address
Is Dog Spayed/Neutered?
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Does dog need full exam? *
Current HW Status *
HW Test Needed *
Proheart Injection? (Heartworm Prevention for 6 months) *
Rabies Vaccination *
DHLPP Vaccination *
Bordatella *
Fecal? If yes please Sonoma's Haven Manager so they know to get sample *
Would you like blood work ran? *
Microchip Needed (Will Scan Prior to Chipping) *
Spay/Neuter Needed? (If HW+ Dog must've complete HW treatment prior to surgery) *
If getting spayed or neutered would you like dew claws removed if not attached? *
Please List Any RX Medication Dog Is Currently Taking & Dosage (Put N/A if none) *
Any Known Medical Conditions? Please Explain Below - (If you have any records for conditions please email to N/A if none *
Has the dog had blood work ran recently? *
Please Mark Any of These Symptoms Currently/Recently Seen In The Dog *
If Other Was Selected Please Explain Below-
Heartworm Treatment Needed? *
Please explain if other selected above
If Heartworm treatment is needed have they already started doxy? If so when?
Please mention any concerns you would like to vet to look at or additional treatment not listed above.
Please provide contact information for foster if dog is getting dropped off for HW Treatment or S/N.
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