Veterinary Reference Form
KANSAS CITY SIAMESE RESCUE
Printable Veterinary Reference Form
P.O. Box 1245, Lee's Summit, MO 64063
816-331-9700
www.kcsiameserescue.org
Date:
To Whom It May Concern:
____________________________ has applied to the Kansas City Siamese Rescue center to adopt one of our available animals. 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 or dog 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
Printable Veterinary Reference Form
P.O. Box 1245, Lee's Summit, MO 64063
816-331-9700
www.kcsiameserescue.org
Date:
To Whom It May Concern:
____________________________ has applied to the Kansas City Siamese Rescue center to adopt one of our available animals. 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 or dog 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
