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KANSAS CITY SIAMESE RESCUE Printable Veterinary Reference Form P.O. Box 1245, Lee's Summit, MO 64063 (816) 252-2991 or (816) 869-3368 www.kcsiameserescue.com Date: To Whom It May Concern: ____________________________ has applied to the Kansas City Siamese Rescue center to adopt a Siamese Cat. Kansas City Siamese Rescue would like to obtain a reference to ensure we are making the appropriate placement. We would appreciate your time in assisting us by filling out this reference form. Name of Clinic:_____________________________________ Vet Name:__________________________________________ Address:______________________________________________ City:______________________________ State:____________________________ Zip:________________ Phone:____________________ Fax:_________________________ How long have you known this client?____________________ Would you consider him/her a responsible pet owner?______________(yes or no) Is/Are his/her animal(s) up-to-date with their shots?___________(yes or no) Have they ever been tested for Feline Leukemia?__________(yes or no) Results:_____________________ (positive or negative) Are there any reasons why you would NOT recommend placement of a Siamese (or other breed) cat with this client? ______________________________________________________ ______________________________________________________ ______________________________________________________ Any other comments? ______________________________________________________ ______________________________________________________ May we telephone you if needed?____________(yes or no) Signature:______________________________________ Date:_________________________ PLEASE RETURN TO: KANSAS CITY SIAMESE RESCUE P.O. BOX 1245 LEE'S SUMMIT, MO 64063 |
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