Drake Dog Cancer Foundation - Pet Parent Intake Form

Drake Dog Cancer Foundation - Intake Form

Help us understand your dog's health condition to recommend the best products for canine cancer support.
Owner's Full Name*

First NameLast Name
Owner's Email Address*
example@example.com
Owner's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Dog's Name*
Dog's Breed
Male or Female?

MaleFemale
Dog's Age (years)*
Dog's Weight (pounds)*
What is your dog currently eating (brand, type, frequency)?
Has your dog been diagnosed with cancer by a veterinarian?*

YesNo
If yes, when was your dog diagnosed?
Type of cancer diagnosed*
Type of Cancer Diagnosed
Stage of cancer*
How is your dog currently feeling/acting (energy level, appetite, mood)?
Would you like suggestions about how to cope with your dog's diagnosis?
Does your dog have any other health conditions?

ArthritisHip DysplasiaAllergiesDigestive IssuesHeart DiseaseOther
If other, please explain here:
Medications your dog is currently taking
Supplements your dog is currently taking
Has your dog begun any treatments for cancer?
Are there any other pets in the home?*

YesNo
If yes, what other pets are in the home?
Are there family members in the home?*

Yes- AdultsYes- Adults and ChildrenNoOther
Do you have a veterinary oncologist for your dog?*

YesNo
Other members of your dog's cancer care team (e.g., nutritionist, physical therapist)
Questions/Comments- How can we best help you and your sweet pup?
Are you a part of our Facebook community?

YesNoOther
Are you interested in any specific products?

SupplementsMedicinal TreatsHealing OilsSupportive DevicesOther
What type of products are you looking for?
What are your goals for your dog’s care? (e.g., prolong life, improve comfort/quality of life, maintain appetite)
File Upload

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Drake Dog Cancer Foundation - Intake Form