Blood Donor Program – Register your Dog Canine Blood Donor Program Registration OWNER INFORMATION Name First Name Last Name Address Address Line 1 Address Line 2 Suburb(required) State(required Postal Code Email Mobile phone Alternative phone PRIMARY CARE VETERINARIAN INFORMATION Regular Veterinarian: Veterinary Clinic: CONSENT FOR BLOOD DONATION I give consent for an initial health check, which includes physical examination, temperament assessment, blood tests, +/- urine analysis. I am aware that no additional fee is incurred for these tests. Results will be shared with my regular veterinarian. I understand that blood donation may require sedation and/or general anaesthesia. It is the priority of Queensland Veterinary Specialists/Pet Emergency to provide our donors with a safe and positive donation experience. I understand the risks associated with sedation/general anaesthesia and consent to sedation/anaesthesia if required. I understand that to minimise infection, small areas of hair will need to be clipped from my dog’s neck and legs. I, the owner, hereby give consent for my dog to donate blood under the care of Queensland Veterinary Specialists/Pet Emergency. Signature Date PET INFORMATION Pet's name Pet's breed Pet's age Pet's date of birth How old was your dog when you obtained him/her? Pet's sex MaleFemale Spayed/Neutered: YesNo Vaccination C3C5C7None Vaccination product name and date received Heartworm prevention YesNo Heartworm product name and date received Tick prevention YesNo Tick prevention product name and date received Flea prevention YesNo Flea prevention product name and date received Has your dog ever received a blood/plasma transfusion YesNo Has your dog ever received Tick Antiserum YesNo Has your dog ever received Snake Antivenom YesNo Has your dog ever been pregnant? YesNo Does your dog go outdoors unsupervised? yesno Do you travel with your dog? If so, where? Does your dog have or has your dog had any medical conditions/illnesses? Please provide details Is your dog receiving any medications or supplements? Has your dog been a blood donor previously? Please provide details OWNER DECLARATION I declare that all information provided is accurate to the best of my knowledge, as failure to do so may place my dog and others at risk. Signature: Date
