Rescue Contact Information Form

Legacy Vet Clinic Rescue Contact Information

If this is the first time your rescue has requested an appointment, please complete this form.

Rescue Name(Required)

Main Contact Name(Required)

First Last

Phone Number for Main Contact(Required)

Rescue Email Address(Required)

Email Address Confirm Email Address

Additional Contacts

If we are unable to get a hold of the main contact, please add additional names of people that are allowed to make medical or financial decisions. Leave blank if there is only one contact.

First

Last

Phone Number

Address of Rescue(Required)

If the rescue address is a PO Box, a physical address is also required.

Street Address Address Line 2 City State ZIP Code

Physical Address - Administrative Purposes Only

This is for internal use only and will not be give out to any fosters, clients, or third parties.

Street Address Address Line 2 City State ZIP Code

Preferred Method of Contact

Additional Service Approval(Required)

Would you like to be contacted if the veterinarian recommends other services? If you select yes, we will not perform additional services until we have permission.

Approval Limits

Please either provide the maximum dollar amount you will approve without being contacted and/or what services you will always approve.

Other Comments

Please add any additional information we need to know about your rescue.

Signature

CAPTCHA

This field is for validation purposes and should be left unchanged.

Legacy Vet Clinic Rescue Contact Information

If this is the first time your rescue has requested an appointment, please complete this form.

Rescue Name(Required)

Main Contact Name(Required)

First Last

Phone Number for Main Contact(Required)

Rescue Email Address(Required)

Email Address Confirm Email Address

Additional Contacts

If we are unable to get a hold of the main contact, please add additional names of people that are allowed to make medical or financial decisions. Leave blank if there is only one contact.

First

Last

Phone Number

Address of Rescue(Required)

If the rescue address is a PO Box, a physical address is also required.

Street Address Address Line 2 City State ZIP Code

Physical Address – Administrative Purposes Only

This is for internal use only and will not be give out to any fosters, clients, or third parties.

Street Address Address Line 2 City State ZIP Code

Preferred Method of Contact

Additional Service Approval(Required)

Would you like to be contacted if the veterinarian recommends other services? If you select yes, we will not perform additional services until we have permission.

Approval Limits

Please either provide the maximum dollar amount you will approve without being contacted and/or what services you will always approve.

Other Comments

Please add any additional information we need to know about your rescue.

Signature

CAPTCHA

This field is for validation purposes and should be left unchanged.

Legacy Vet Clinic Rescue Contact Information

Legacy Vet Clinic Rescue Contact Information

Appointments

Veterinary Pet Services & Pricing

Site Links

Location

Clinic Hours