Medical Services Intake – Bay Area One Health Coalition

Medical Services Intake & Record Form

Date of Visit:

1. PET INFORMATION

Pet Name: *

Species: *

Sex: *

Pet Date of Birth:

Approximate Age:

2. OWNER INFORMATION

First Name: *

Last Name: *

Email Address: *

Phone Number:

Addresss:

City

Zip Code:

3. MEDICAL INFORMATION

Spayed / Neutered *

DAPPv / HCP Next Vaccine Due Date: *

Dewormer:

Flea Treatment:

4. PHOTOGRAPHY AND MEDIA RELEASE (OPTIONAL)

Approval for past use and permission for present and future use is being granted to Onederwork Inc DBA Project Pet, 2323 Broadway, Oakland CA, 94612 to use photographs or other images taken during Project Pet activities of the photographed party and their pet, as more fully explained in this Consent and Release. The Photographed Party is an adult, the legal owner of the pet being photographed, and is fully authorized to sign this Consent and Release.

For value received, receipt of which is hereby acknowledged, the Photographed Party hereby grants consent to Onederwork Inc, its agents, employees, licensees, and successors in interest (collectively, the Released Party) and authorizes the use of any and all photographs taken of her, and any reproduction of them in any form in any media whatsoever and in any derivative work based thereon throughout the world, and to use them to publicize, promote and advertise, including but not limited to use for point of sale advertising.

The Photographed Party also consents to the use of her own name or any fictitious name which may be chosen in connection with the aforesaid photographs. The Photographed Party hereby releases any and all claims whatsoever in connection with the use of her photograph and name and the reproduction thereof as aforesaid.

The Photographed Party hereby waives any right that she may have to inspect and/or approve the Book or the advertising copy that may be used in connection therewith or the use to which it may be applied.

THE PHOTOGRAPHED PARTY WARRANTS THAT SHE IS THE UNDERSIGNED AND THAT SHE HAS READ THIS CONSENT AND RELEASE PRIOR TO THE SIGNING OF THIS DOCUMENT, THAT THE UNDERSIGNED UNDERSTANDS IT, AND THAT THE UNDERSIGNED FREELY ENTERS INTO THIS CONSENT AND RELEASE

Printed Name:

Date:

Signature: (Check to sign) *

5. AUTHORIZATION, LIABILITY RELEASE & EMERGENCY RESPONSIBILITY

I certify I am the owner/caretaker and authorize services. I release Project Pet, Staff, and Volunteers from all liabilities. I understand Project Pet is not an emergency provider; I am solely responsible for all follow-up care costs and complications. I certify my animal is not aggressive and accept responsibility for any injury caused.

Printed Name: *

Date: *

Signature: (Check to sign) *

Vaccine:

6. POST-VACCINATION CARE & EMERGENCY CONTACT

Seek vet care immediately for: Difficulty breathing, facial swelling, hives, collapse, seizures, severe lethargy, repeated vomiting, bloody diarrhea, or pale gums. Project Pet is NOT an emergency provider.

I consent to receiving updates from BAOHC.

How It Works

From Outreach to Empowerment

Community-Based Outreach

We meet people where they are - at encampments, community centers, and on the streets - building trust before delivering services. Our community health workers conduct culturally competent, trauma-informed outreach.

Animal-Assisted Therapy Sessions

Through partnerships with animal welfare organizations, we deploy AAT in accessible settings. Participants engage with trained animals as a bridge to emotional resilience and readiness for additional services.

Peer Navigator Integration

SB803-certified Peer Navigators with lived experience are embedded in every program. They build long-term relationships with participants, acting as both guides and advocates throughout the wellness journey.

Wrap-Around Services Coordination

We connect individuals to a full spectrum of services - mental health, substance use treatment, housing support, veterinary care, legal aid, and economic opportunity - through our One Health Micro-Clinic model.

Workforce Development & Reintegration

For those ready to build stable employment, we provide certified training in animal care, e-commerce, and peer navigation - creating sustainable pathways to economic independence.

Medical Services Intake & Record Form

Medical Services Intake & Record Form

1. PET INFORMATION

2. OWNER INFORMATION

3. MEDICAL INFORMATION

4. PHOTOGRAPHY AND MEDIA RELEASE (OPTIONAL)

5. AUTHORIZATION, LIABILITY RELEASE & EMERGENCY RESPONSIBILITY

Project Pet Representative

A. STAFF ONLY - Medical Services

6. POST-VACCINATION CARE & EMERGENCY CONTACT

B. PROJECT PET OWNER'S RECORD COPY

From Outreach to Empowerment

Community-Based Outreach

Animal-Assisted Therapy Sessions

Peer Navigator Integration

Wrap-Around Services Coordination

Workforce Development & Reintegration

Support Our Approach