KENTUCKY DACHSHUND RESCUE, INC.

109 CRAIGMOOR ESTATES--GEORGETOWN, KY.  40324

 

 

                                                                    

      

1-502-863-5447

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VERA FORM

PET EMERGENCIES

 

 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                                           $25-30     CHARGE

DISTEMPER/ADENO//PARVO/LEPTO/CORO $28-30 CHARGE 

BORDATELLO (ONLY SHELTER DOGS)        $23      CHARGE

HEARTWORM TEST                                     $20-22   CHARGE

RABIES                                                        $10-12    CHARGE

FECAL                                                        $10-12    CHARGE

SPAY/NEUTER                                            $60-$85   CHARGE

PRE-OP BLOOD WORK (DOGS OVER 7)        $20       CHARGE

TRIM NAILS                                                 $7-9         CHARGE

MEDS FOR SKIN MITES/EAR MITES/RESPIR  $10      CHARGE

TREATMENT FOR POS FECAL MEDS             $30       CHARGE

ALL OTHER INFORMATION (EXPLAIN) 

SICK DOG VET EXPENSES

OFFICE VISIT                                              $30       CHARGE 

EMERGENCY AFTER HRS                            $75       CHARGE 

GEN BLOOD PROFILE CHEM                       $60       CHARGE

IV WITH LACTATED RINGERS                 $30-35        CHARGE

HOSPITALIZATION                                     $35         CHARGE

HEARTWORM TREATMENT                    $100-150      CHARGE

DENTAL CLEANING/EXTRACTIONS        UP TO $150 CHARGE

SPINAL/BROKEN BONES    CALL THE OFFICE

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