City, State, Zip:
Alternate Telephone Number:
Pet’s Date of Birth:
Male UnneuteredMale NeuteredFemale UnspayedFemale Spayed
Primary Care Veterinarian/Veterinary Clinic:
If female, has she ever been pregnant or had a little of puppies?
Is he/she used for breeding?
Does he/she have any current medical problems?
If yes, please list the issues:
Do you give or apply a heartworm preventative?
Is he/she current on vaccinations?
Has he/she ever received a blood transfusion?
Has he/she ever lived in or traveled to any of the following states or regions: Ohio, Oklahoma,
Texas or the Southwest United States?
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)?