Blood Donor Team Application
We have just a few specifications that we need our donors to meet:Dogs:At a healthy weight of at least 50lbs, between the ages of 1-7 years old.Up-to-date on Rabies and distemper vaccines and on year-round heartworm/flea/tick preventative.No history of serious diseases.Donors are asked to visit to our hospital for blood donation approximately once every 3 months.Be people-friendly and generally healthy. *Please note that some medications may exclude your dog from the blood donor program.
First Name
*
Last Name
*
Phone Number
*
Please enter a valid phone number.
Email Address
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Veterinarian
*
Pet's Name
*
Pet's Approx. Age
*
Breed
*
Weight
*
Spayed/ Neutered?
Yes
No
Current on Rabies / Distemper? (able to provide proof?)
*
Yes
No
Current brand of heartworm medication your pet takes:
*
Current brand of flea/ tick medication your pet takes:
*
Has your pet been on preventatives consistently for the past 6 months?
*
Yes
No
If no, please describe:
Please list all medications your pet takes (that not listed above):
*
Has your pet ever received a blood donation?
*
Yes
No
If yes, please explain:
Does your pet receive apoquel (pill) or cytopoint (injection)
*
Yes
No
Does your pet have any allergies, if so please explain: (type N/A if not applicable)
*
Has your pet ever had problems with any of the following? (Check all that apply)
*
Skin or eyes
Bleeding disorders
Muscle or bone
Heart or Lungs
Lumps or Bumps
Kidney or Urinary Tract
Any tickborne illness (Lyme, Ehrlichia, Anaplasmosis, etc)
Stomach, Intestinal, or Liver
None of the above
Other
If so, please explain
Has your pet ever shown any signs of aggression towards people or other animals?
*
Yes
No
If yes, please explain:
Is your pet comfortable being picked up and "held/snuggled" They will be donating laying on their right side with a human holding them from behind
*
Yes
No
Unsure
How long have you had this pet?
*
We do like for new pet's to have acclimated to your home for about 6 months. We like you to know them well and what makes them tick before we teach them a new trick.
Is your pet currently on a raw diet?
*
Yes
No
Can we clip/shave your pet's donation site? The neck over jugular vein is shaved and prepped for donation.
*
Yes
No
I understand the first visit with us will be an evaluation. They will have their behavior and willingness to participate evaluated in a positive happy visit to us.
*
Yes
No
If your pet is a good fit, are you able to visit at least 4-6 times per year?
*
Yes
No
I understand that my pet’s initial visit will consist of an evaluation and blood typing. Blood testing is to ensure that my pet is in excellent health and will be performed at the first donation. I understand that after fulfilling his/her obligations to AEH my pet will be eligible to receive blood products and emergency credits should medical or surgical circumstances arise which warrant its use (elective procedures excluded). I understand that this eligibility is non-transferable to other pets. If your pet is needing emergency blood, please do not delay in seeking medical treatment for your pet but please contact the blood bank immediately so that we can negotiate replacement of any blood products used for our donors.
*
I will do my best to attend 4-6 donations during the next 12 months. I understand that requests for donations will be at least 5 weeks apart. I understand that a minimum of 4 donations per year are necessary for my pet to be eligible for the benefits described above. I understand that AEH and its staff cannot function as the ”veterinarian” for my pet. I am obligated to remain current with my regular veterinarian’s health and vaccination schedule, including hw/flea/tick prevention. Please note that there may be times during the year where we will need to reschedule due to weather, emergency, illness, or lack of donors to cover our travel. This will be no fault of our donors.
*
I understand that if my pet, without provocation, attacks or injures any person or other animal who is acting peaceably in any place where the person or animal may lawfully be, I am personally liable in damages to the person or pet so attacked or injured to the full amount of the injury sustained.
*
Additional Information
Upload your proof of current vaccination here:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Submit
Should be Empty: