Canine – Pre-Screening Survey

Name

First Last

Pet's Name

First

Number

Best Time To Call

Address

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

How old is your dog? Must be 1-9 years old.

How long ago did you obtain your dog? Must be at least 6 months.

What breed is your dog?

Is your dog spayed or neutered? If female, has your dog ever had a litter of puppies?

How much does your dog weigh? Dogs must weigh at least 50 lbs.

What is your dog’s temperament like at your veterinarian?

Is your dog up to date on vaccines? Distemper combo and Rabies vaccines are required.

Yes

Is your dog on heartworm, flea and tick prevention once monthly and year round? Please specify the product names.

Please list any medications your dog is currently on.

Does your dog have any pre-existing conditions?

Has your dog ever received a blood transfusion?

Has your dog ever been diagnosed or treated for a bleeding disorder, seizures, diabetes mellitus, cushings or addisons disease, liver, kidney or heart disease?

Does your dog have any food allergies or special diet? What is your pet's current diet?

What days of the week are you available to bring your dog to the hospital for screening or donation?

Can we request your dog’s medical records from your regular veterinarian? If yes, can you provide your veterinarian's information (clinic and doctor’s name and location)?

How did you hear about this program?

62646

Canine – Pre-Screening Survey

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