Group Information

    Group Name

    Address

    Address2

    City

    State

    ZIP

    Phone

    Email

    Point of Contact

    Name

    Phone

    Email

    Dog Information

    Dog Name

    Age

    How the dog came into your rescue:

    Description of the Medical Procedure(s) required/performed:

    Name of Veterinarian and Clinic

    Documentation

    Please provide as much of the following as possible
    Please attached an itemized bill

    Please attached a paid receipt