Office Use Only
CHS Reference Number:______

4455–110 Avenue S.E., Calgary, AB, T2C 2T7

Pet Safekeeping/Emergency Boarding (403) 205-4455 ext. 6527 (Weekdays)

Animal Admission (403) 723-6025 (Evening and Weekends)

Fax: (403) 723-6050

Email: Website:

PET SAFEKEEPING PROGRAM

REFERRAL FORM (SHELTERS)

Referral Date (m/d/y) ______

Referral Source:

Agency Name ______

Contact Person ______

Phone Number ______

E-mail ______

Client Information:

Name ______

Phone ______

(Is it safe to leave detailed messages at this number? Yes No)

Date entered shelter (m/d/y) ______

Date exiting shelter (m/d/y) ______

Children present: In relationship? Yes No In current incident? Yes No

Were the children exposed to threats or abuse towards the animal(s) Yes No

Pet Information:

CHS
Ref No.
(Petlynx) / Name / Type/Breed (Cat, Dog, Other (please specify) / Sex
(F/
M) / Age / Spayed/
Neutered
(Yes/No/
Unknown) / Date of last
Vaccination / Vet Clinic
Used

If animal(s) is not spayed or neutered we offer a complimentary spay/neuter?

Comments (behavioural issues, dietary requirements, medical concerns, safety concerns, etc.): ______

For safety and security reasons, please provide the following information concerning the abusive person:

Pet abuse reported:
Current abuse? Yes No (If “Yes”, Threatened Actual Both)
Past abuse? Yes No (If “Yes”, Threatened Actual Both)
If you answered yes to either of the above questions please give a brief description:
______
______
What is your relationship to the abusive person? ______
Do you think the abuser will try to find the animal(s)? Yes No Don’t know
Does the abusive person have any legal claim to the animal(s)? Yes No Don’t know
Name ______
Gender Male Female / Hair Colour ______/ Eye Colour ______
Height ______/ Weight ______/ Age/Date of Birth ______
Place of Residence______
Place of employment ______
Home and Work number ______
Please provide a description of the abusive person’s vehicle:
Make ______/ Model ______
Year ______/ Colour ______
Licence place number ______
Do you have a photograph of the abusive person that we can keep or copy? Yes No

Emergency Contact Information (Someone other than the Owner)

Name______

Phone______

Address______

Please list the areas of the city that would cause you to have safety concerns for your animal being placed for foster. ______

______

Referral Agency Designate Sign and Date

Updated Dec 2012