Canine Blood Donor Agreement 2019-04-03T15:33:33+00:00

Canine Blood Donor Agreement

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