Owner Name:
Street Address:
City, State, Zip:
Telephone Number:
Alternate Telephone Number:
Email Address:
Pet’s Name:
Pet’s Date of Birth:
Breed:
Sex: Male UnneuteredMale NeuteredFemale UnspayedFemale Spayed
Primary Care Veterinarian/Veterinary Clinic:
If female, has she ever been pregnant or had a little of puppies? YesNoNA
Is he/she used for breeding? YesNo
Does he/she have any current medical problems? YesNo
If yes, please list the issues:
Do you give or apply a heartworm preventative? YesNo
Is he/she current on vaccinations? YesNo
Has he/she ever received a blood transfusion? YesNo
Has he/she ever lived in or traveled to any of the following states or regions: Ohio, Oklahoma, Texas or the Southwest United States? YesNo
If yes, which one?
Is your dog any of the following breeds (check all that apply)? American Pit Bull TerrierEnglish FoxhoundGreyhoundAmerican Staffordshire Terrier
How did you hear about our blood donor program (check all that apply)? RadioWebsiteFacebookNewsletterFriend/FamilyYour Veterinarian
