Medical Intake Request

EARPS works closely with shelters and vet clinics where animals are at risk of euthanasia. This form is for veterinary clinics ONLY and should be used as a last resort to request intake of a medical case who may not survive without our intervention. If you require an urgent response, you can also text us at 317-809-2153, but as our rescue is run by all volunteers with full time jobs, we are not always able to connect immediately.
Date: *
I. Vet Clinic Information
Clinic Name: *
Contact Full Name: *
Clinic Email: *
Clinic Phone: *
Original Owner First Name: *
Original Owner Last Name: *
Original Owner Email: *
Original Owner Phone: *
What steps have you taken to assist the owner in keeping their pet? *
Have you already accepted surrender of this animal? *
Has the owner paid for all treatment to date? *
Is owner able to pay additional surrender fees? *
II. Surrender Details
Can you provide up to date vet records for each animal? *
Please describe the current issue in detail. *
Please describe the current treatment plan. *
What is the estimate for the treatment described? *
Does your clinic offer a rescue discount to assist with the treatment plan? *
Is your clinic able to continue treatment or are you planning to refer elsewhere?
What cages, supplies, and food would be coming with the animals? * We request cages, supplies, and food whenever possible to ease an animal's transition into our rescue. Please advise owner they will need to deliver these items if their animal is accepted.
III. Animal Information
Are there cagemates who will be surrendered with the sick/injured animal? *
How many animals will be surrendered? *
Animal Name(s): *
Species: *
Description (Please include breeds, markings, colors, personality, medical history or behavior issues.) *
Gender: *
Have the animal(s) been altered? *
Age: *
IV. Other Information
Is there anything else you would like us to know?

Medical Intake Request

I. Vet Clinic Information

II. Surrender Details

III. Animal Information

IV. Other Information