Large Animal Intake Form

Large Animal Intake Form

Date Arrived __________________ ‘ Rescued ‘ Owner Brought

Intake number _________________ Assigned Shelter Location _______________________

If rescued, Date rescued ______________________ Location __________________________

Date Discharged _______________

Species: ‘Cattle ‘Sheep ‘Swine ‘Horse ‘Goats ‘Other _____________________________

Owner’s/Rescuer’s name _______________________________________________________

Address _______________________________________________________________________

Number and street City Zip

Phone ( ) ________________________ Cellular ( ) ________________________

Fax ( ) ________________________ Pager ( ) ________________________

Individual Animal Identification

Identification
(E.g., Brand/tattoo) Description, registration
name or number
Age Sex Breed

1. _____________________ ____________________________ _____ _____ _________

2. _____________________ ____________________________ _____ _____ _________

3. _____________________ ____________________________ _____ _____ _________

4. _____________________ ____________________________ _____ _____ _________

5. _____________________ ____________________________ _____ _____ _________

6. _____________________ ____________________________ _____ _____ _________

7. _____________________ ____________________________ _____ _____ _________

8. _____________________ ____________________________ _____ _____ _________

9. _____________________ ____________________________ _____ _____ _________

10. _____________________ ____________________________ _____ _____ _________

Accepted by (staff) _______________________________________Date ____________

Owner’s signature ________________________________________Date ____________

Released by _____________________________________________Date ____________

Owner’s signature ________________________________________Date ____________
^{Adapted from Indiana’s State Annex for Veterinary
Emergencies Committee.

_________________

Draft On- line for

Nevada Animal Disaster Preparedness Guide

The draft was provided by the California Office of Emergency Services.

http://www.cdaf.ca.gov/programs/disasterprep.htm

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