Authorization for Veterinary Treatment
V-SLIP #
Date
(Required)
MM slash DD slash YYYY
Activity Number
(Required)
Animal ID
(Required)
Department Code
(Required)
Department Code
COS Animal Care- 225
COS ALE- 200
COS Vet Clinic- 921
COS Wellness Clinic- 922
Foster Care- 276
PUB Animal Care- 474
PUB ALE- 400
PUB Vet Clinic- 421
PUB Wellness Clinic- 422
Centennial ALE- 232
Douglas County ALE- 230
Animal Name
(Required)
if no name, enter "none"
Animal Color(s)
(Required)
Animal Breed(s)
(Required)
Veterinary Clinic
(Required)
Veterinary Clinic
Animal ER Care
Mesa Veterinary Clinic
North Springs Veterinary Referral Center
Powers Pet ER & Specialty
Pueblo Area Pet ER Hospital
Colorado Veterinary Specialty Group
Animal Emergency & Specialty Center
Veterinary Specialists of the Rockies
Other
Veterinary Clinic Email
(Required)
Enter Email
Confirm Email
List Veterinary Clinics Full Name & Address
(Required)
Animal Care
(Required)
This animal has NOT been seen by a veterinarian
No medications have been administered
This animal has been seen by a veterinarian and medical records will be provided
Additional treatment and/or procedures have been requested and are authorized for reimbursement to include the following:
Additional notes/comments
Additional treatment/procedures
(Required)
Additional notes/comments
(Required)
Above named clinic is authorized to examine and perform medical procedures on above described animal to stabilize and relieve pain. Without consent of Humane Society, cost is not to exceed:
(Required)
Approved by
(Required)
First
Last
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