CARE's Blood Donor Pre-Screening Questionnaire
Please answer the following questions correctly. This will help to protect your pet and the pets that may receive your pet's blood. You will be asked for your pet's vaccination due dates, please have this ready as you complete this form.
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Has your pet ever been a patient of CARE?
*
Yes
No
I have been here with another pet
Pet's Name
*
First Name
Last Name
Owner's Name
*
First Name
Last Name
Owner's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Is your pet between the ages of 1 and 6 years old?
*
Yes
No
Pet Birth Date
-
Month
-
Day
Year
Date Picker Icon
Microchip #
Primary Care Clinic:
*
Is your pet a Canine or Feline?
*
Canine (dog)
Feline (cat)
Gender:
*
Male
Female
Is your pet spayed/neutered?
*
Yes
No
Does your pet meet the minimum weight requirement? Felines - 10lbs Canines- 55lbs
*
Yes, my cat is more than 10 pounds
Yes, my dog is more than 55 pounds
No, my pet does not meet the weight requirement.
Due Date of Rabies Vaccine:
*
-
Month
-
Day
Year
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Due Date of DHPP Vaccine:
*
-
Month
-
Day
Year
Date Picker Icon
Date of Last Heartworm Test:
*
-
Month
-
Day
Year
Date Picker Icon
Date of Last Labwork (primarily a 4DX):
*
-
Month
-
Day
Year
Date Picker Icon
Is your pet on a Flea/Tick/ Heartworm prevention?
*
Yes
No
What brand of Flea/Tick/ Heartworm prevention do you use?
*
When was the last time your pet received their Flea/Tick/ Heartworm prevention?
*
-
Month
-
Day
Year
Date Picker Icon
Have you ever missed a month of Heartworm Prevention?
*
Yes
No
Does your pet take any other medication?
*
Yes
No
If yes, please list below:
*
Does your pet have any chronic medical conditions?
*
Yes
No
If yes, please list below:
Does your pet or household have any allergies we should know about?
*
Yes
No
Please list below:
Does your pet have a good temperament?
*
Yes
No
Does your pet have a history of any of the behaviors listed below?
*
Fear
Aggression
Biting
None of the Above
Does your pet like to be snuggled/hugged/loved on?
*
Yes
No
What is your pet's favorite treat?
*
Have you traveled with your pet recently?
*
Yes
No
Where were you traveling and how long ago was it?
Is it okay to shave your pet to collect the donation?
*
Yes
No
Has your pet ever received a blood transfusion?
*
Yes
No
Has your pet ever been a Blood Donor before?
*
Yes
No
If yes, when was the last time your pet donated blood?
-
Month
-
Day
Year
Date Picker Icon
Are you able to commit to 1 donation a quarter? (4 per year)
*
Yes
No
Are you willing to be an on-call donor if we urgently need a donation?
*
Yes, anytime
No
Yes, weekdays
Yes, weekends
Are you available Wednesdays or Thursdays for the in-hospital screening and collection days?
*
Yes
No
If you have any of your pet's records, please attach them here:
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