Rescue Discount Application Form

Please fill out this form as completely and accurately as possible.

Who is filling out this application:(Required)

Position/title:

General Rescue Information

Rescue Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Main phone number(Required)

Main email address(Required)

Website

Primary Vet Clinic(Required)

General code status(Required)

Yes/CPR

No/DNR

Yes under only certain circumstances (elaborate)

Elaborate(Required)

Primary Contact (who do we contact if a rescue shows up at ACES and we are looking for medical/plan approval):

Name(Required)

Position/title

Phone number(Required)

Email address(Required)

Secondary Contact (who do we contact if the primary contact cannot be reached):

Name(Required)

Position/title

Phone number(Required)

Email address(Required)

Financial Contact (who do we send invoices to):

Name(Required)

Position/title

Phone number(Required)

Email address(Required)

Additional Contact:

Name

Position/title

Phone number

Email address

We will send medical records and discharges to the primary contact unless otherwise noted here:

Attach proof of 501c3 status(Required)

Max. file size: 50 MB.

Media Release

With your authorization, we may use photos, video, non-identifying medical information and treatment outcomes in media releases to Facebook, Instagram, Twitter (X), or other social media. We promise to use this information responsibly and only in a positive light. Rescue retains the right to revoke authorization and posts will be removed at request. We may, on occasion, use the same information in business deliverables (pamphlets, handouts, website pages or other). We will expressly inform the Rescue of this intended use. Revocation of authorization in this instance will not be possible as it would be at great cost to ACES to remove these materials from circulation once printed.(Required)

I agree to allow ACES to use Rescue pets, their likeness, and medical history in the manner described above.

I DO NOT allow ACES to use my pet, their likeness, and medical history in the manner described above.

Signature(Required)

Date(Required)

Agreement Statement

I understand and acknowledge on behalf of the rescue listed on this application that any approved discounts will not be applied retroactively towards the cost of care and are only eligible from the point of approval onwards.(Required)

I understand and acknowledge on behalf of the rescue listed on this application that any approved discounts will not be applied retroactively towards the cost of care and are only eligible from the point of approval onwards.

I understand and acknowledge on behalf of the rescue listed on this application that ACES reserves the right to alter or discontinue use of a rescue discount at any time for any reason and without notice.(Required)

I understand and acknowledge on behalf of the rescue listed on this application that ACES reserves the right to alter or discontinue use of a rescue discount at any time for any reason and without notice.

I understand that balances on accounts are due in full at time of receipt of invoice.(Required)

I understand that balances on accounts are due in full at time of receipt of invoice.

Signature(Required)

Date(Required)

Rescue Discount Application Form