OWNER INFORMATION

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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

YYYY

PET INFORMATION

Pet's name

Pet's breed

Pet's age

Pet's date of birth

YYYY

How old was your dog when you obtained him/her?

Pet's sex

Male

Female

Spayed/Neutered:

Yes

Vaccination

None

Vaccination product name and date received

Heartworm prevention

Yes

Heartworm product name and date received

Tick prevention

Yes

Tick prevention product name and date received

Flea prevention

Yes

Flea prevention product name and date received

Has your dog ever received a blood/plasma transfusion

Yes

Has your dog ever received Tick Antiserum

Yes

Has your dog ever received Snake Antivenom

Yes

Has your dog ever been pregnant?

Yes

Does your dog go outdoors unsupervised?

Yes

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

YYYY

Canine Blood Donor Program Registration

If you have a patient that would benefit from specialist care.

Call Stafford on 07 3008 9313 or North Lakes on 07 3883 5206 to make an appointment.