Feline – Pre-Screening Survey

Name(Required)

First Last

Pet's Name(Required)

First

Email(Required)

Phone Number(Required)

Best Time To Call(Required)

Address

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

How old is your cat? Cats must be between the ages of 1-9 years old.(Required)

How much does your cat weigh? Cats must weigh at least 9 lbs.(Required)

How long ago did you obtain your pet? Must be longer than 6 months.(Required)

Is your cat spayed or neutered? If female, have they ever had a litter of kittens?(Required)

What breed is your cat? (i.e., DSH,Siamese)(Required)

What is your cat’s temperament at the veterinarian?(Required)

Is your cat indoor only? Does your cat hunt mice indoors?(Required)

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

What is your cat's current diet? Does your cat have any dietary restrictions or food allergies?(Required)

Is your cat up to date on vaccines? Combo FVRCP and Rabies vaccines are required.(Required)

Yes

Do you foster or pet-sit other cats?(Required)

Yes

Has your cat ever received a blood transfusion?(Required)

Yes

Health History

Please list any medications your cat is currently on.(Required)

Does your cat have any pre-existing conditions?(Required)

Has your cat ever been previously diagnosed or treated for any of the following: a. Bleeding disorder, seizures, Diabetes mellitus, Cushing’s or Addison’s disease, liver, kidney or heart disease?(Required)

What days of the week are you available to bring your cat to the hospital for screening or donation?(Required)

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

How did you hear about the blood bank program?

58147

Feline – Pre-Screening Survey

Health History

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