Prospective Canine Donor Questionnaire

Prospective Canine Donor Questionnaire
Owner and Dog Information
Owner Name

First NameMiddle NameLast Name
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City/State/Zip
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail Address
example@example.com
Pet’s Name
Breed(s)
Sex
Spayed/Neutered
Age
Approximate Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Weight
How old was your dog when you obtained him/her?
Medical History and Preventative Care
Approximate date of last vaccinations - Distemper/Parvo

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approximate date of last vaccinations - Rabies

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approximate date of last vaccinations - Leptospirosis

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approximate date of last vaccinations - Other
Is your dog currently on Heartworm Preventative?
Approx. date of last HW test?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is your dog currently on Tick/Flea Preventative?
Tick/Flea Preventative - Describe
Has your dog had any health problems, even minor ones – in the past or currently? Please describe
What is your dog’s current diet?
Is your dog on any medications?
Has your dog ever received a blood or plasma transfusion?
Has your dog ever been pregnant?
Do you travel with your dog?
If yes, where?
Donation Readiness and Consent
Are you comfortable with 3” area of hair to be clipped from your dog’s neck?
Initial Screening: I, the undersigned owner or the agent of the owner of the above-described pet, give
permission for the doctor(s) and staff of Best Buds’ Lasers and Blood (BBLB) to perform an initial exam of
my pet and collect lab specimens, for submission, to determine if my pet is a blood donor candidate. I
understand there is no fee incurred today. If there are abnormal findings that prevent my pet from
becoming a blood donor, I understand it is my responsibility to follow up and incur any charges for further
diagnostics or treatment.
Signature of Owner or Agent
Date (Owner/Agent Signature)

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

Prospective Canine Donor Questionnaire

Owner and Dog Information

Medical History and Preventative Care

Donation Readiness and Consent