Please complete this form to request medical assistance for each sick C.A.T.S. foster animal:

Foster's First Name*

Foster's Last Name*

Email*

Phone Number* (cell preferred)

Can you send/receive text messages at this number?*
Yes
No

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Dog/Cat's Name*

Male or Female*
Male
Female
Can't Tell

Dog/Cat's Age*

Dog/Cat's Weight*

Dog/Cat's Description* (color, pattern, breed)

Is this animal sharing food/water bowls with any other animals?
Yes
No

If a cat, is it sharing a litterbox with any other cat(s)?
Yes
No

Have you given any medication to date?
Yes
No

If yes, what, how much & when did you start?

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ENERGY: On a scale of 1 to 5 where 1 is hardly moving and 5 is normal playfulness, where does your foster rate?

APPETITE: On a scale of 1 to 5 where 1 is not eating at all and 5 is normal appetite, where does your foster rate?

THIRST: On a scale of 1 to 5 where 1 is not drinking at all and 5 is normal thirst, where does your foster rate?

EYES:
Any discharge from the eyes?
Yes
No

If yes, what color is the discharge from the eyes?
Clear
Red/Brown
Yellow/Green

NOSE:
Any discharge from the nose?
Yes
No

If yes, what color is the discharge from the eyes?
Clear
Red/Brown
Yellow/Green

MOUTH:
Any sores on the tongue, mouth or in the throat?
Yes
No

BREATHING:
Have you noticed any of the following symptoms? (check all that apply)*
Breathing through the mouth
Sneezing
Coughing
Rasping/Labored breath

OTHER:
Please note any other symptoms that you have noticed with this foster animal