Veterinary Referral Associates Blood Donor Questionnaire

Veterinary Referral Associates Blood Donor Questionnaire

Complete this multi-page questionnaire to help VRA screen your pet for potential volunteer blood donation—submission does not guarantee acceptance.
Photo Release
Photo Release Preference
Owner Information
First Name
Last Name
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Pet Information
Pet Name
Species
Breed
Color
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approximate Age (Years)
Current Weight (lbs)
Sex
Spayed/Neutered
Microchip Number
Indoor-only?
Primary Veterinarian
Veterinarian / Practice Name
City
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Acknowledgement

Other
Vaccines & Preventatives
Rabies vaccine status
Heartworm prevention status
Heartworm prevention product name
Flea/tick prevention status
Flea/tick prevention product name
Preventatives given consistently during the past 6 months?
Explanation for any gap, interruption, or unknown status
Medical History
Current health status
Has your pet had any significant illnesses?
If yes, please describe the significant illnesses
Has your pet had any surgeries or a previous blood transfusion?
If yes, please provide details of surgeries or blood transfusion
Has your pet ever had an adverse reaction to medication, sedation, or anesthesia?
If yes or unsure, please explain the reaction and circumstances
Medications, Allergies & Diet
Current medications and supplements
Medication allergies or adverse reactions
Food allergies or intolerances
Is your pet currently on a raw-food diet?
Reproductive History
Is this pet currently used for breeding?
For female dogs only: Has this pet ever been pregnant?
Behavior & Handling
Aggression toward people
Please explain the aggression toward people
Aggression toward other animals
Fear or anxiety during veterinary visits
Comfort with handling and restraint
Comfort lying on side for blood collection
Permission to clip or shave the blood collection site
Travel & Background
Has your pet traveled or lived outside the Mid-Atlantic region?
How long have you had this pet?
Screening & Donation Scheduling
Tuesdays are VRA’s primary screening and donation days. Screenings are generally either a 1-hour appointment from 10 AM–2 PM or a morning drop-off/evening pickup. Donations are generally morning drop-off/evening pickup.
Do Tuesdays generally work for screening or donation visits?
If Tuesdays do not work, which alternate weekdays could work?
For future donations, does morning drop-off/evening pickup work for you?
How Did You Hear About Us?
How did you hear about us?

Other
If referred by a person, who referred you?
Final Acknowledgement
Typed Owner Name

First NameLast Name
Submission Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Veterinary Referral Associates Blood Donor Questionnaire

Photo Release

Owner Information

Pet Information

Primary Veterinarian

Vaccines & Preventatives

Medical History

Medications, Allergies & Diet

Reproductive History

Behavior & Handling

Travel & Background

Screening & Donation Scheduling

How Did You Hear About Us?

Final Acknowledgement