VERA FORM

		VERA FORM
		VETERINARY EXPENSES REIMBURSEMENT AGREEMENT VERA FORM FOR FOSTERING MEMBERS OR VOLUNTEERS ..ONLY!!!! KDR will reimburse for the following "standard" procedures, if necessary. Intake: Dogs that come in MUST have a surrender form and indicate what procedures they currently have. Dogs already current on Rabies vaccine MUST have a certificate or Rabies tag. If not, the procedure must be repeated. YOU SHOULD ALREADY HAVE A VET RELATIONSHIP ESTABLISHED PRIOR TO INTAKING A PET. TAKE THE FOLLOWING LIST TO YOUR VET TO VERIFY HIS APPROVAL OF OUR PAYMENT FOR HIS FEES. Schedule an office visit within 24 hrs of intake for dog to receive : RABIES, HW check, DAPPLC shots, FECAL AND BORDATELLO. KEEP DOGS QUARANTINED UNTIL SHOTS HAVE BEEN GIVEN . SCHEDULE AT A LATER TIME THE NEUTER/SPAY/MICROCHIP...SUBMIT THE FOLLOWING FORM TO THE OFFICE FOR PAYMENT OF YOUR VET EXPENSES. YOU MUST USE YOUR FOSTER ID IN ORDER TO SUBMIT THIS FORM. ONLY YOU KNOW WHAT THAT IS. INDICATE IF YOU WANT US TO PAY THE VET OR DIRECTLY TO YOU.... DATE DATE OF SERVICE PUR OR NAME OF DOG FOSTER ID FOSTER'S NAME PHONE FOSTERS ADDRESS CITY STATE ZIP VET NAME VET ADDRESS VET CITY STATE ZIP I AM REQUESTING THE FOLLOWING AMOUNTS FOR VETTING FOR THE ABOVE PET PLEASE PAY THE VET PAY ME DIRECTLY COPIES OF ACTUAL BILLS WILL BE FAXED TO OFFICE BEFORE PAYMENT WELL DOG VET EXPENSES OFFICE VISIT $37.80 CHARGE DISTEMPER/ADENO//PARVO/LEPTO/CORO $18 CHARGE BORDATELLO (ONLY SHELTER DOGS) $14 CHARGE HEARTWORM TEST $27 CHARGE RABIES $11.25 CHARGE FECAL $14.40 CHARGE SPAY/NEUTER GAS $49.50 $75s/$50n CHARGE PRE-OP BLOOD WORK (DOGS OVER 7) $36 CHARGE TRIM NAILS $11.70 CHARGE MEDS FOR SKIN MITES/EAR MITES/ACAREXX $15 CHARGE TREATMENT FOR POS FECAL MEDS $16 CHARGE ALL OTHER INFORMATION (EXPLAIN) SICK DOG VET EXPENSES OFFICE VISIT $37.80 CHARGE EMERGENCY AFTER HRS $100 CHARGE GEN BLOOD PROFILE CHEM $72 CHARGE IV WITH LACTATED RINGERS/ CATHETER $26.10 FLUIDS $40.50 DAY CHARGE HOSPITALIZATION $22.50 NIGHT CHARGE HEARTWORM TREATMENT $150 IF NO BLOOD WORK CHARGE DENTAL CLEANING/EXTRACTIONS UP TO $150 CHARGE SPINAL/BROKEN BONES CALL THE OFFICE MEDICATIONS FUROSEMIDE (27) 20 MG 30.00 SIMPLICEF 24.61 ADEQUAN 14.00 PENICILLAN 16.20 STRONGID 22.50 DRONTAL 7.50 CEPHALEXIN .73 CLINDAMYCIN 14.04 TOBRAMYCIN 17.86 CBC 40.50 DIAGNOSTIC FLU 72.00 METROMAZOLE .88 X RAYS 112.50 METACAM 52.43 FLUID TREATMENT 20.70 REGLAN 19.80 FORTI FLORA PKT 32.37 DENAMARIN 43.11 CYTOLOGY 19.80 BAYTRIL 20.00 PHENOBARB 60.00 INJECTION HI CAL 11.88 ENAPRIL (2.5) 31.53 SKIN SCRAPING 22.50 THYROID 36.00 ALL OTHER SICK DOG INFORMATION (EXPLAIN) SUBTOTAL $ DISCOUNTS $ TOTAL AMOUNT REQUESTED $ FUTURE VET EXPENSE EXPECTED PLEASE DESCRIBE PROCEDURE AND AMOUNT By signature below, I certify I have read and understand the above information and conditions. I further certify I understand that if I submit a bill to KDR for any other medical treatment or services other than what is listed above without first obtaining prior approval from KDR, I may not be reimbursed for these other expenses and personally will be held financially accountable to the veterinarian for same

KDR will reimburse for the following "standard" procedures, if necessary.

Intake: Dogs that come in MUST have a surrender form and indicate what procedures they currently have. Dogs already current on Rabies vaccine MUST have a certificate or Rabies tag. If not, the procedure must be repeated.