Join K9 Blood Buddies

OWNER INFORMATION

Your Name*

Your Address* (include city, state, zip)

Main Phone*

Email Address*

How did you hear about the K9 Blood Buddies program?*

PET INFORMATION

(If you have more than one potiential candidate please re-submit this form for each pet)

Pet's Name*

Breed*

Pet's Approximate Weight in Pounds*

Date of Birth/Approximate Age*

Gender*
Select OneMaleFemale

Spayed or Neutered*
Select OneYesNo

Please answer the following donor requirement questions*

Is your dog 1-9 yrs of age?*

Select OneYesNo

Is your dog over 50 pounds?*

Select OneYesNo

Is your dog friendly, obedient & even-tempered?

Select OneYesNo

Will your dog lie calmly on it's side for 10-15 min?*

Select OneYesNo

Has your dog had any serious diseases?*

Select OneYesNo

If yes, please explain.

Has your dog ever received a blood transfusion?

Select OneYesNo

Is your pet on any medications other than heartworm prevention?*

Select OneYesNo

If yes, please list all medications, duration and frequency.

Has your dog ever been pregnant?*

Select OneYesNoN/A

Is your pet in heat?*

Select OneYesNoN/A

Is your pet current on the following vaccines: rabies, distemper, hepatitis, parainfluenze and parvovirus?*

Select OneYesNo

Can you provide us with written documention of these vaccinations from a licensed veterinarian?*

Select OneYesNoThey are on file with your hospital.

Can your pet be "on-call" for urgent blood donation requests 24 hrs a day?* Answering "no" will not eliminate your pet from being a candidate.

SelectYesNoMaybe-would like more info

COMMENTS OR QUESTIONS

By typing your name in the below signature box you are verifying that all the information provided is true to the best of your knowledge. K9 Blood Buddies program is not intended for the diagnosis or treatment of any disease, illness or injury. Dogs that do not qualify for the program due to medical reasons will be referred to their primary veterinarian for treatment. Animal Health Services and K9 Blood Buddies staff reserve the right to reject any pet without reason or cause.

I have read and understand the above statement

Signature (required)

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