Animal Seizure Intake Form

Animal Intake Form

Incident: ______Intake Personnel Name: ______Title: ______

Date: ______Case # ______Animal ID # ______Animal Transport # ______Agency or Team: ______

Animal Stats Name Species Breed Color/Markings Gender Known ID  Dog  Female  Collar  Cat  Male  ID Tag  Other Altered  License: ______ Yes  Rabies:______ No  Microchip:______ Tattoo:______

Initial Evaluation Behavior:  Friendly  Shy/Cautious/ Fearful  Aggressive  Biter/Bite Hold

Animal Health Status:  Emergency Medical  Medical Care Advised  Stable  Pregnant  Deceased

Medical Exam: Date: ______Veterinarian: ______ Examined  Treatment Sheet Filed

Final Evaluation Disposition:  Returned to owner  Deceased  Euthanized

 Adopted Name: ______Address: ______Phone: ( ) ______( ) ______

 Transferred Organization: ______Address: ______Contact: ______Phone: ( ) ______( ) ______

Final Behavioral Evaluation Behavior:  Friendly  Shy/Cautious/ Fearful  Aggressive  Biter/Bite Hold

Exit Personnel/Evaluator Name: ______Title: ______