Veterinary Follow Up

Service Dog/Facility Dog Veterinary Follow-Up

This form is to be filled out by a veterinarian.
ACTS has placed a Service Dog or Facility Therapy Dog with one of your clients.

As part of their agreed upon follow-up procedure, we are asking you to fill out this short form.

Keeping track of our placed dogs and their care is a large part of our follow-up and we appreciate your taking the time to keep us informed of the dogs care and upkeep.

Thank you!
ACTS - Assistance Canine Training Services
2928 East Conway Road
Center Conway, NH 03813
603-383-2073
info@assistancecanine.org
IMPORTANT INSTRUCTIONS: Please read carefully

Please use your TAB key to move on to the next entry box.

This form MUST be filled out in one session. If you leave the session, the form will NOT be saved.
Client
Date*

MonthDayYear
Date
Client Name*
Dog Name*
Veterinarian
Today's Date*

MonthDayYear
Date
Veterinarian Name*

First NameLast Name
Veterinary Hospital Name*
Veterinarian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Veterinarian Phone*

Area CodePhone Number
Medical Information
Most recent weight of the dog*
What date was this weight recorded?
Can you rank this dog's BCS on the 1-9 scale?*
Is this dog current on vaccinations or titers?*
To the best of your knowledge, do you know if this dog is being treated with heartworm prevention and monthly flea and tick prevention?*
Does this dog receive a Lyme vaccine?*
Has this dog had any chronic medical issues over the past year?*
Has this dog experienced any medical issues over the past year that may have been genetically passed to him/her?*
Has this dog been involved in any accidents or had any illnesses that may indicate neglect?*
Does this dog appear generally well groomed, brushed, bathed, and cared for?*
Do you have any other comments or concerns?*
I acknowledge that by submitting my name and signing below, that all the above information is accurate.
Name*

First NameLast Name
Please Sign and Submit*

Clear
When you click the SUBMIT button, the final version of this form will be sent to ACTS.
Should be Empty:

Service Dog/Facility Dog Veterinary Follow-Up