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 Name
Last Name
Owner's Email Address
*
example@example.com
Owner's Phone Number
*
Please enter a valid phone number.
Dog's Name
*
Dog's Breed
Male or Female?
Male
Female
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?
*
Yes
No
If yes, when was your dog diagnosed?
Type of cancer diagnosed
*
Please Select
Lymphoma
Osteosarcoma
Mast Cell Tumor
Hemangiosarcoma
Melanoma
Other
Type of Cancer Diagnosed
Stage of cancer
*
Please Select
Stage I
Stage II
Stage III
Stage IV
Unknown
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?
Arthritis
Hip Dysplasia
Allergies
Digestive Issues
Heart Disease
Other
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?
*
Yes
No
If yes, what other pets are in the home?
Are there family members in the home?
*
Yes- Adults
Yes- Adults and Children
No
Other
Do you have a veterinary oncologist for your dog?
*
Yes
No
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?
Yes
No
Other
Are you interested in any specific products?
Supplements
Medicinal Treats
Healing Oils
Supportive Devices
Other
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)
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