If this is a true emergency – please go to your nearest veterinarian or emergency clinic for support; neither Connecticut Humane Society nor Connecticut Humane Society’s Fox Memorial Clinic are equipped for emergency care. Appointments are required for all visits. If you need help with a pet that has non-emergent medical needs, please complete the following form as fully and accurately as possible. We strive to respond to all messages within 2 business days.Have you contacted CHS about your need for assistance already?*NoYesPlease enter the hotline/case number from your call:*Please reach out to the Connecticut Humane Society at 860-594-4500 to speak to a representative before completing this form. Applications submitted without an initial phone call will not be processed. What kind of support services are you requesting?* Medical treatment Euthanasia (end of life) Unsure/Undecided In a couple of words, explain what condition(s) you would like help treating: (there will be room to explain further down):*What is your primary reason for requesting euthanasia?* Quality of my pet's life Quality of my life Financial constraints Other If other, please explain:*Details:*CONTACT INFORMATIONDate* MM slash DD slash YYYY Name:* Mr.Mrs.MissMs.Dr.Prof.Rev.Mx.None Prefix First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone:*Secondary Phone:Email:* Preferred method of contact:* Phone Email How did you hear about Connecticut Humane Society (CHS) and Fox Memorial Clinic (FMC)? I am an FMC client From a friend/family Social media From my veterinarian From CCEH (Connecticut Coalition to End Homelessness) I am a CHS/FMC volunteer I am a CHS employee I am a CHS adopter PET INFORMATIONPet's Name:*Age or DOB:*Breed(s):*Approximate weight:*Sex and spay/neuter status:* Intact male (not neutered) Altered male (neutered) Male – unsure if he’s neutered Intact female (not spayed) Altered female (spayed) Female – unsure if she’s spayed Do you own this pet?* Yes No What is your relationship to the owner of this pet?*Is the owner of this pet aware you are seeking medical care for their pet?*How long has this pet been in your care?*Where did you get this pet?*Does this pet have a regular veterinarian?* Yes No Provide the contact information for your regular veterinarian:*Why have you chosen to seek support through Connecticut Humane Society/Fox Memorial Clinic?*CASE SPECIFICSPlease describe the issue(s) for which you are seeking support. Be specific:*How long has this problem been present?*Has the problem been getting worse?* Yes No Details:Have you been to a veterinarian or emergency clinic for this specific concern?* Yes No When?*Please provide the contact information for the treating veterinarian/clinic.*Do you have a diagnosis, recommended treatment plan, and/or an estimate for care from any veterinarian?*Upload any medical documents you have from the vet. Drop files here or Select files Max. file size: 256 MB. Has this pet ever been to a veterinarian?* Yes No When was the last time the pet was seen by a veterinarian?*Please provide the contact information for the veterinarian.*Upload any medical documents you have from the vet. Drop files here or Select files Max. file size: 256 MB. Have you tried to treat this problem?* Yes No Please describe what you have done to try and treat the problem and who prescribed this plan.*Is this pet on any medication(s) or special diet?* Yes No Please list the medications, including dosage, and/or special diet:*Has this animal ever received a rabies vaccine?* Yes (must provide proof) No (My pet will need the rabies vaccination required by CT State Law) Unsure (My pet will need the rabies vaccination required by CT State Law) You will need to provide a rabies certificate from the veterinarian who gave the vaccine. Please upload it here.Max. file size: 256 MB.Do you authorize us to contact your veterinarian(s) and receive medical records of your pet?* Yes No Please provide the contact information for any other veterinarian your pet has seen (excluding the vets you already listed above):Reviewing your pet’s prior medical records will give us the best chance to help your pet. If you do not want us to contact your veterinarian, please upload your pet’s complete medical records here. Drop files here or Select files Max. file size: 256 MB. LOCATIONS AND SERVICESPlease read the following information before making a selection below. CHS’ Fox Memorial Clinic is a donor-subsidized clinic offering a wide range of veterinary services for cats and dogs. Fox does not currently see pocket pets. If your cat or dog has a complicated medical condition, or will need x-rays, Fox Memorial Clinic may be the best location to address your pet’s needs. Fox Memorial Clinic also offers euthanasia services and, if it is safe to do so, owners may choose to be with their pet during the procedure. CHS' Newington and Westport shelters offer limited veterinary services for cats, dogs, and pocket pets. If your pet has a minor condition, Newington or Westport may be able to assist. Newington and Westport also offer euthanasia services, but owners may not remain with their pet during the procedure. CHS’ Waterford shelter does not currently offer public veterinary services. Waterford does offer euthanasia services. Owners may not remain with their pet during the procedure. Considering the service availability outlined above, to which location would you like to direct your request for support? *Note that if you choose to direct your form to a location that is not equipped to handle your request, based on the descriptions above, it will delay the response time.* Fox Memorial Clinic, 701 Russell Road, Newington Newington Shelter, 701 Russell Road, Newington Waterford Shelter, 169 Old Colchester Road, Quaker Hill Westport Shelter, 455 Post Road East, Westport CAPTCHA
