HARRISON MEMORIAL ANIMAL HOSPITAL (HMAH)
          
                                 2008 Application
                      
                    Veterinary Service Application

    

While this application is focused on Animal Shelters 
and Rescue Groups if you are neither one of these groups 
please indicate unrelated questions with N/A.

 

Please complete this application making sure that all items are addressed and return to:

Alicia Dzialo
Harrison Memorial Animal Hospital
191 Yuma St.
Denver, CO 80223
Fax: 303-871-7029

___________________________________________________________________________                                                                                                                                                             

 
Name of Organization: __________________________________________Phone # __________________________

Street Address/ PO Box  _____________________   

City_________________State  _____Zip ______

 

Who will be the Contact person from your organization to Harrison Memorial Animal Hospital:

Name: ______________________________ Phone  _________________________________                                                                            

Chief Executive Officer or President of the Organization (if different than above)
Name_____________________________________

Title_____________________Phone   ___________

Type of Facility (s) (shelter, rescue group, non-profit school, etc.):  ______________________________________________________________                                                                                                                                                   

Address of Facility: ______________________________________________________                                                                                                                    

______________________________________________________                                                                                                  

 
Hours of Operation: __________________   Days of Operation: ___________________ 

Types of Animals Accepted (please check all that are appropriate):

 Dogs:_____    Cats:_____   Birds:_____    Other (Specify)____________

 Under What Conditions Do You Accept Animals: (Please attach copies of any policies, procedures or forms used in this process: i.e. owner releases, etc.
______________________________________________________________________________

_______________________________________________________________________________
_______________________________________________________________________________

 Policies Regarding Length of Time You Hold Animals: (Please attach copies of policies and any forms that you require or use.)  _____________________________________________________________________________________________                                                                                                                                                                                               

__________________________________________________________________________________________________
                                                                                                                                                                                                        
__________________________________________________________________________________________________

_______________________________________________________________________________________

 Adoption Procedures: (Please attach any forms used.)

 1.         How do you screen adopters?  _________________________________________________________________________                                                                                                                                                                                        

_______________________________________________________________________________________
                                                                                                                                                                                                               

2.        What is your spay/neuter policy? 
______________________________________________________________________________________                                                                                                                                                                        

____________________________________________________________________________
                                                                                                                                                                    
____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________                                                                                                     

____________________________________________________________________________
                                                                                                                                                   

 What Are Your Adoption Fees:            Cats: $ _______  Dogs: $______

 What does this include? (i.e. Vaccinations, S/N, etc.)  _________________________________________________________________________________________

 _________________________________________________________________________________________
 
_________________________________________________________________________________________                                                                                                                                            Financial

Financial Information: How is funding acquired? (i.e. donations, adoption fees, government funding, grants, bingo, etc.)

 Annual Budget for Year: $ ____________
 Income: $   ______________      Expenses: $  ___________                 

(Please include copies of most recent financial statements.)

Does Your Organization Have Non-Profit Status?                                 Yes ______    No  _______ 

(If so, please attach a copy of your 501(c)(3) Tax Exempt Letter or proof of status.



Do You Have Rescue Funds Available Through A National Purebred Organization (Breed Specific Rescue Groups Only)?

 Yes _____    No _____    If so, approximately how much?: $ _____________


Names of Two (2) People Authorized To Schedule Appointments:

Name#1 :  _______________________  

Telephone Numbers: 
Home: ___________________________________                                                                       

Work : ___________________________________                                                                       

Cell   :  ___________________________________                                                                      

Fax   :  ___________________________________                                                                       


Name#2 : _________________________________  

Telephone Numbers: 
Home:   ___________________________________                                                                     

Work :  ___________________________________                                                                      

Cell   :  ____________________________________                                       

Fax   :  ____________________________________                                                                      

 

 

I certify that this organization adheres to ethical practices of humane animal care and abides by all state and local policies. I also understand that Harrison Memorial Animal Hospital has the right to visit any and all facilities associated with this organization/shelter at any time and that the information provided in this application is true and accurate to the best of my knowledge.

 _______________________________       ______________________       ___________

President or Chief Executive Officer                       Title                                        Date












                       HARRISON MEMORIAL ANIMAL HOSPITAL (HMAH)           

                                    Policies and Requirements

                                                For Organizations 

                            Receiving Veterinary/Hospital Services at HMAH

 The following is a list of policies, procedures and conditions for animal welfare agencies receiving discounted services
at HMAH.  These criteria have been established to facilitate a mutually beneficial relationship between your agency
and HMAH in accordance with the mission of HMAH, generally accepted veterinary medical practice and the needs of
your agency and the animals in your care.  A signed copy of this Policy Agreement will be kept on file at HMAH.  
It is suggested that all members of your group be given a copy of this agreement for their reference.

 

1.         An Application for Veterinary Services will be completed before initial services are provided and updated annually
by each organization.

 

2.         All animals in the care of your organization must be identified in a way that can be recognized by HMAH to insure
the maintenance of accurate medical records.

 

3.         Routine office call appointments must be scheduled separately from those appointments needed for spay/neuter
surgeries.

 

4.         HMAH reserves the right to refuse service to any agency that misrepresents the ownership status of any animal
presented to us for care.

 

5.         HMAH requires that all vaccinations be given by a veterinarian (whether HMAH staff or other) or under the direction
of a veterinarian.  Written certification by a veterinarian is required for HMAH to recognize vaccinations given by
members of your organization as valid.

 

6.         When an animal is scheduled for an appointment, whether spay/neuter or office call, please notify the front office as
soon as possible if you need to substitute that animal with another animal.  Also, please schedule any additional
animals for separate appointments.  Consistently missed appointments may result in the addition of a "NO SHOW"
fee of $ 25 added to your account.

 

7.         HMAH considers emergencies as "life threatening" incidents.  Please keep this in mind when requesting an
emergency appointment.  If you have a sick animal, we will try to schedule an appointment for you to be seen as
soon as possible.  In the event that you come to HMAH without an appointment and there is no emergency, you
may be scheduled an appointment on another day.

                                                                                                                             Continued on page 2



Page 2

Policies & Requirements For Organizations Receiving Services at HMAH

 8.  Please designate two members of your staff to make all appointments needed at HMAH (spay/neuter and office call). 
These individuals will be the only authorized personnel to schedule appointments unless a change is submitted in writing
to HMAH. 

 

9.    Foster Homes:  (If utilized by your agency.)  A complete list of foster homes used by your organization is to be kept on
file at HMAH.  This list should consist of the name, address and telephone number for each home.  Any changes in
this list must be submitted in writing to HMAH.

 

Any animal in a specific foster home for more than six months will be considered by HMAH to be owned
by that foster home.  At that point, the foster home (owner) must qualify for services as a regular client. 
Use of your rescue or shelter account will not be available to that owner.

 

10.     Representatives of HMAH reserve the right to visit any and all properties and facilities associated with your agency at
any time and for any reason.  In addition, HMAH will notify the appropriate authorities in the event that neglect
and/or abuse is suspected.

 

11.     Payment is expected at time of service for all veterinary care provided at Harrison, unless prior arrangements have
been made with our front desk. HMAH will not carry balances on rescue group accounts for more than 30 days.

 

 

I have read these policies and conditions and agree to adopt them as part of my/our relationship with Harrison Memorial
Animal Hospital.

 

  

_________________________________                      _________________________________     

            Signature                                                                Date

  

__________________________________                      __________________________________    

Signature                                                                Date