Rescue Medical Treatment Plan Form

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Email *

Today’s Date *

YYYY

Full Name of Person Completing Form *

Rescue Organization *

Dogs Name *

Approximate Age (If Known)

Weight Est. (Best Guess)

Sex *

Female

Male

Breed (Best Guess) *

Color *

Health Certificate needed? If yes select which HC needed. Please ensure rabies certificate is emailed to sonomashaven@gmail.com subject Dogs Name Rabies Certificate. We cannot complete without a rabies certificate on file. *

7001-Electronic HC - This is only an option through Dr. Chellgren needs to be completed during her visit.

Tri-carbon copy paper HC

N/A

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?

Yes

Not Sure

Clear selection

Does dog need full exam? *

Yes

Current HW Status *

Negative

Positive - If Positive Needs to complete HW Treatment before S/N

Unsure - If Positive Needs to complete HW Treatment before S/N

HW Test Needed *

Proheart Injection? (Heartworm Prevention for 6 months) *

Yes

Rabies Vaccination *

DHLPP Vaccination *

Bordatella *

Fecal? If yes please Sonoma's Haven Manager so they know to get sample *

Yes (If yes and dropping off please have foster bring fecal from day before with dogs name on fecal. Can be in dog poop bag.)

Would you like blood work ran? *

Yes

If vet feels it should be ran please run bloodwork

Please run Senior Panel

Microchip Needed (Will Scan Prior to Chipping) *

Spay/Neuter Needed? (If HW+ Dog must've complete HW treatment prior to surgery) *

Yes

Maybe - Please Check if you are not sure if dog is spay/neutered

If getting spayed or neutered would you like dew claws removed if not attached? *

Yes

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 sonomashaven@gmail.com) N/A if none *

Has the dog had blood work ran recently? *

Yes (Please send to sonomashaven@gmail.com)

Please Mark Any of These Symptoms Currently/Recently Seen In The Dog *

Coughing

Diarrhea

Lethargic

None

Other:

Required

If Other Was Selected Please Explain Below-

Heartworm Treatment Needed? *

N/A

2 Injections

3 Injections

Other - Please explain if Other

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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