Dog Blood Donor Evaluation Form | Prescott Animal Hospital

Is your pet healthy

Weighs at least 55lbs

On flea/ tick and heartworm prevention

No previous tranfusions

Is spayed / neutered

Is up to date on vaccines

Owner Name(Required)

Telephone(Required)

Email Address(Required)

Address

Street Address

Address Line 2

City

State

ZIP Code

Pet's Name

Breed

Sex

Spayed/Neutered

Age

Approximate Birthday

Weight

How old is your dog when you got him/her?

Distemper/Parvo

Rabies

Heartworm Test

Fecal

Is your dog currently on heartworm preventative?

Is your dog currently on flea/tick preventative (list type)?

Has your dog had any health problems (even minor ones) – in the past or currently? Please describe:

Is your dog on any medications other than flea/tick/heartworm prevention? Please describe:

Has your dog ever received a blood or plasma transfusion?

Has your dog ever been pregnant?

Do your travel with your dog?

Are you comfortable with a 3-5 inch area of hair to be clipped from your dog’s neck?

All Vaccinations & Tests have to be done before proceeding for Canine Blood Donor Evaluation

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