BROOD is happy to pay your veterinary expenses. Please print and fill out the following form and attach it to your vet bill/records. Send to:

Diane Morgan

15213 Clear Spring Road

Williamsport MD 21795

Dog’s Name _____________________Number _____________

Foster Name ____________________________ Phone ________________

Address _________________________________

________________________________________

Email _________________________

Date of Visit ______________________

Veterinarian Name __________________________Phone ________________

Address ___________________________________

__________________________________________

TOTAL AMOUNT OWED ___________________

Pay YOU ___________ Vet ___________________

Reason for visit (check all that apply):

Exam ___________ Recheck Exam __________

Core Vaccination _________________ Please be specific! (DAPP-L, D-P Puppy, etc.)

Rabies ________ Rabies tag # ____________

Lyme vaccine ______________Kennel Cough _____________

Lab test:

CBC ________ Chem. Profile ______ Pre-Op Profile _______________

Stool________ Urinalysis________ Heartworm _______Other ___________

X-rays _________ Ultrasound _________

Spay/Neuter ________________ Dental ____________

Glaucoma or other eye check _________

Seizure ___________________Bloat __________________

Lump/cyst removal _____________ Result_________________

Orthopedic problem _________________

Ear infection/cleaning ___________________

Wound/Injury/Abscess ____________________

Other: __________________________

Medication prescribed ___________________

General remarks (Use other side if necessary):