Friday, May 09, 2008
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Blood Donor Enrollment Form
Last Name
 *
First Name
 *
Middle Initial
Home Phone
 *
Work Phone
Date
 *Cal
Street Address
 *
City
 *
State
 *
Zip
 *
Place of Employment
Referring Clinic
Pet Name
Species
Breed
Age
Color
Sex Neutered
Vaccinations
Is your dog greater than 55 pounds?
Is your dog between the age of 2 and 6?
Does your dog have a temperament to lie on his side for 5 minutes?
Is your dog on any medication?
What are they?
Is your dog current on vaccines?
Have you had your dog since puppy hood?
May we contact your regular veterinarian for a copy of your animal records?
Will you keep your dog current on all routine immunizations?
Will you bring in a fecal sample for examination every 6 months?
Will you bring your dog in once per year for routine blood analysis?
Will you maintain your dog on heartworm preventative medication year round (We will provide the preventative)
Will you bring your dog for donation of blood at least every 3 months?
Has your dog ever had a litter of puppies or a blood transfusion?
If you answered no to any question (except the last question) your dog may not be eligible to donate blood.  Please let us know of any extenuating circumstances.
On the, hopefully rare, occasion we use all the blood collected for a given month, will you be willing to receive a phone call and bring your dog in for an emergency donation should the need arise? 
This will hopefully not happen, but sometimes many dogs may need blood on the same day.
What time is unacceptable to call? (Please take work schedule and sleep time into consideration)

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