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Brookview Animal Wellness Rescue Partner Agreement

RESCUE:

Rescue Information

ANIMAL RESCUE:

TAX ID #:

LEGAL REPRESENTATIVE:

MAILING ADDRESS:

Phone:

FAX:

Website:

Facebook:

Instagram:

APPOINTMENTS:
Appointments may only be scheduled by those identified in this agreement. Appointments made by individuals not listed on this form will not be accepted. Cancellations must be done 24 hours in advance. No show appointments / last minute cancellations (less than 24-hour notice) will be charged a $15 fee after the first two missed appointments per rescue per quarter during the calendar year.

HOURS OF OPERATION:
Surgery admit times are staggered. Scheduled patients must be dropped off during scheduled surgery admit time. Failure to drop off during assigned period, will be treated as a no-show. You will be given a minimum of one-hour notice when animals are ready to be picked up. All animals must be picked up by closing time or may incur a $25 late fee. Same day add-ons will not be accepted nor patient swaps.

CARRIERS:
Each feline must be in their own individual hard-sided carrier or trap (for ferals). Each carrier should be labeled with Rescue Name, Animal Name, Transporter Name, Contact # and services requested. This allows us to verify that the original appointment information needs match the current needs of the animal. Failure to list services on carrier may result in them not being completed.

RESTRAINTS:
Each canine must have a neck collar and arrive on leash. Retractable leashes, choke chains and harnesses without a neck collar will not be accepted. Smaller dogs are encouraged to be in carriers and follow carrier instructions above.

PRE-SURGERY:
We highly recommend that every cat / dog have a minimum of one core vaccine (FVRCP (cats), DHPP (dogs) prior to alter. All cats / dogs need to be free of illness for at least seven days and have no signs of infection / illness at time of alter. Please bring relevant medical history to surgery. All animals will be examined prior to surgery as allowed by patient temperament. Proceeding with surgery and / or services is at the sole discretion of the doctor.

By bringing animals for surgery, the rescue has verified that said animals have not been exposed to any communicable disease within the last seven days. Additionally, the animal(s) have not shown aggression, bitten, inured or killed any animal or person.

All dogs three months and older are required by state law to have a current rabies vaccine. If you cannot show proof of a current valid rabies vaccine, the dog will receive a rabies vaccine at time of alter at rescue expense.

All animals 5+ years of age require pre-anesthetic bloodwork. It can be completed at another veterinary clinic no more than ten days prior to surgery or day of surgery for additional cost.

SURGERY:
Additional charges may apply if the animal(s) are overweight, pregnant, recently or active in heat or cryptorchid. We highly recommend the use of e-collars to protect your animal’s incisions. If you decline an e-collar and your animal requires a follow-up veterinary visit due to licking or scratching the incision, an exam fee will be charged.

We tattoo all animals once sterilized. All cats brought in for TNR (in a trap) will be ear-tipped. You can elect to have non-TNR cats ear-tipped if needed.

Anesthesia, surgery, medications, vaccines all involve some inherent risk to animals. We take reasonable precautions against escape, injury or death of the animals in our care.

POST-SURGERY:
Post-surgery instructions are standard and will be provided upon establishing this agreement. Please provide them to your fosters in advance. Should there be additional instructions, they will be provided at time of release to transporter. If there are any concerns post-surgery, contact the main line for assistance during open hours. For urgent or emergent concerns outside business hours, please seek emergency care at AVECCC. Post-surgery costs are the responsibility of the owner / rescue.

RELEASE / HOLD HARMLESS:
Brookview Animal Wellness, its owners, veterinarians, employees, representatives, volunteers or any other persons affiliated with Brookview Animal Wellness shall not be held liable for any harm or death that may come to the animals or individuals bringing said animals.

CONTACTS:
Please indicate what each person is responsible / authorized for (Billing, Scheduling, etc):

Primary Contact

Name:

Role:

Email:

Phone:

Additional Contacts

Any More Contacts to Add?

Name:

Role:

Email:

Phone:

Name:

Role:

Email:

Phone:

Name:

Role:

Email:

Phone:

AUTHORIZATION AND CONSENT FOR TREATMENT:
Brookview Animal Wellness, its owners, veterinarians, employees, representatives, volunteers or any other persons affiliated with Brookview Animal Wellness shall not be held liable for any harm or death that may come to the animals or individuals bringing said animals.

Acknowledge that to the above-listed organization’s knowledge, the animals will be in good health and free of infection or illness for a minimum of SEVEN (7) days prior to scheduled surgery. All pre- and post-operative care is our responsibility.
The above-referenced organization authorizes anesthesia/surgery for the animals scheduled by the persons listed at the top of this form. We authorize the use of such anesthetics and vaccinations as the veterinarian deems advisable. We understand that there are risks involved with any living animal undergoing anesthesia and/or surgery. Risks or complications are also possible during the recovery phase of anesthesia and surgery. The nature and risks of this procedure have been explained to us, and we are encouraged to discuss and questions or concerns we may have with the veterinarian or representing veterinary technician before the procedure(s) are started. The signature on this consent form indicates that any questions have been addressed and answered to our satisfaction.
The above-referenced organization authorizes Brookview Animal Wellness and the attending veterinarian(s) to perform any additional diagnostic, treatment or surgical procedure(s) deemed necessary for any medical or surgical complications or any unforeseen circumstances. While Brookview Animal Wellness is dedicated to providing high quality anesthesia monitoring and surgical services, the rescue understands the risks and understand the veterinarian and entire veterinary team will do their best to mitigate those risks. The above-referenced organization hereby releases Brookview Animal Wellness, their agents or representatives from all liability from any complications that may arise.
The above-referenced organization has been provided the prices for the services listed and understand that the prices are without complications. During a surgical procedure, should additional intervention / services need to be performed, additional costs will be the responsibility of the rescue.
The above-referenced organization acknowledges this document has been read in its entirety, understands and will comply with this agreement as of March 28, 2023. Additionally, we will hold harmless and release from liability the owner, veterinarians, employees, contractors, affiliates and volunteers connected to Brookview Animal Wellness.
The above-reference organization permits Brookview Animal Wellness to take photographs of animals present for veterinary care to use for promotional purposes. We * Opt-inOpt-out
to being tagged / named when posted on Brookview Animal Wellness social media channels, website or affiliated links / websites.

PAYMENT:
Payment for all services performed is due on the service date. Provide rescue credit card information below to simplify the payment process. This information will be securely stored only within out veterinary practice management system.

If you do not wish to have a credit card on file, you may be required to provide a deposit at time of appointment confirmation.

Payment in full is due at time of check-out.

Credit Card Authorization

Card Type:

Name on Card:

Card #:

Expiration Date:

CCV Code:

Billing Address:

Street:

City:

State:

Zip:

By signing below, the Rescue acknowledges that leadership has read, understands and will comply with this agreement as of March 28, 2023

Document: BVAW-RPA-2023-01

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Signed by Carrie Neidorf
Signed On: December 28, 2022

Timestamp

Audit

December 6, 2022 1:51 PM MST

Animal Rescue Partner Agreement Uploaded by Carrie Neidorf - legal@bvawellness.com IP 68.14.250.230

Service	Allow	Additional Instructions
FVRCP Vaccine	Allow
FeLV Vaccine	Allow
Rabies Vaccine	Allow
DA2PP Vaccine	Allow
Bordetella Vaccine	Allow
Leptospirosis Vaccine	Allow
Umbilical Hernia Repair	Allow
Cryptorchid	Allow
Unattached Dew Claw Removal	Allow
Symblepharon / Entropion Repair	Allow
Cherry Eye Surgery	Allow
Eye Enucleation	Allow
Stenotic Nares Resection	Allow
Retained Deciduous canine removal	Allow
FeLV / FIV Testing	Allow
4DX/Tick Fever Testing	Allow
Ear-Tip	Allow
Microchip	Allow	Check here if the Rescue will provide microchip
Ear Cleaning & Treatment	Allow
Flea / Tick Treatment	Allow
Fecal and / or Urine Analysis	Allow
Anal Gland Expression	Allow
Bloodwork (CBC & Chemistry)	Allow
IV Catheter / Fluids	Allow
X-Rays	Allow
Nail Trim	Allow
E-Collar	Allow
Other	Allow
Other	Allow
Other	Allow