Small Animal Intake Form

Small Animal Intake Form - Owned Animals with Owner10

Date arrived ________________________ Animal ID #________________________

Date discharged _____________________ Assigned Location ___________________

Owner Information

Name ______________________________________________ Phone # ( ) _____-______________

Address ______________________________________________________________________________

Emergency Contact _____________________________________________________________________

Animal Identification

Species ______________________________ Other ID ______________________________

Breed _______________________________ Size: ‘Toy ‘Small ‘Medium ‘Large ‘Giant

Coat Color ___________________________ Coat Length: ‘Short ‘Medium ‘Long

Age _______________________________ Sex: ‘M ‘M(neutered) ‘F ‘F(spayed)

Medical

Rabies Vaccine? ‘Yes ‘No Tag # ______________ County issued___________________________

Other Vaccines:

Canine: ‘Distemper ‘Hepatitis ‘Leptospirosis ‘Parinfluenza ‘Parvovirus ‘Coronavirus

Feline: ‘Rhinotracheitis ‘Calcivirus ‘Panleukopenia ‘Chlamydia ‘Felv ‘FIP

Any medical problems? ‘No ‘Yes ______________________________________________________

Taking medications? ‘No ‘Yes ________________________________Owner provided? ‘No ‘Yes

Instructions _______________________________________________________________________

Special diet? ‘No ‘Yes _________________________________________ Owner provided? ‘No ‘Yes

Instructions _______________________________________________________________________

Habits and Traits (circle all that apply)

fence jumper	digger	scratcher	submissive	housebroken
highly excitable	biter	shy	leash broken	barker/vocal
declawed			obedience trained	other ________________________

Aggressive toward ‘men ‘women ‘children ‘other animals ____________________________________________________

Accepted by (staff) ___________________________________ Date ___________________

Owner Signature ______________________________________ Date ___________________

Released by ________________________________________ Date ___________________

Owner Signature ______________________________________ Date ___________________

^{10-Adapted from Help Us Get Them to Safety! By the Nevada
County Unit of the CVMA and 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

Back to Draft
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