Prospective Feline Blood Donor
Owner Information
Owner Name:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
E-mail Address:
example@example.com
Donor Information
Pet's Name:
First Name
Last Name
Breed(s):
Sex:
M
F
Spayed/Neutered:
Y
N
Age:
Approximate Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Weight:
How old was your cat when you obtained him/her?
Approximate date of last vaccinations:
Herpes/Calici/Panleuk:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
FeLV:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rabies:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other:
Is your cat currently on:
Heartworm Preventative?
Y
N
Approx. date of last HW test?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Tick/Flea Preventative?
Y
N
Describe:
Has your cat had any health problems, even minor ones – in the past or currently?
Y
N
Please describe:
Does your cat have outdoors access?
What is your cat's current diet?
Is your cat on any medications? (NSAID, aspirin, herbal, supplements, etc.):
Has your cat ever received a blood or plasma transfusion?
Has your cat ever been pregnant?
Do you travel with your cat?
Y
N
If yes, where?
Are you comfortable with 2" area of hair to be clipped from your cat's neck?
Y
N
Are you comfortable with sedation and/or anesthesia of your cat?
Y
N
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Prospective Feline Blood Donor
Authorization to Treat
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:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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