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Theriogenology Intake Form

Pet Name:

Client Name:

Co-owner:

Pet's Registered Name:

AKC Reg. Number:

Microchip#:

DNA Completed:

DNA Completed:
A
B

Date of last Brucellosis screening:

Test Run:

Test Run:

Name of Owner/Stud dog/Bitch to be bred to:

Day this heat cycle began:

Artificial Insemination being performed at our clinic?

Artificial Insemination being performed at our clinic?
A
B

Date of last heat cycle:

Reason for Visit:

Health screening performed:

Health screening performed:
A
B

OFA/PENN HIP HISTORY:

Eye Registry CERF HISTORY:

OTHER SCREENING:

Breeding Counseling:

DIET, MEDICATIONS, & SUPPLEMENTS:

Brand and type of food currently eating:

Is it Grain free?

Is it Grain free?
A
B

Supplements, name, and frequency:

Name of medications if on any and frequency:

PREVENTATIVES:

Name and frequency of Flea, tick, heartworm prevention:

Last time pet got prevention:

Any history of Tick-borne illness (ex: lyme disease, ehrlichia):

Any history of Tick-borne illness (ex: lyme disease, ehrlichia):
A
B

Date of last heartworm test and result:

PREVIOUS BREEDING HISTORY: IF APPLICABLE

FEMALE: First breeding/ Previously bred on:

Outcome:

Timing:

Timing:

Evaluated on palpation/ultrasound/x-ray:

MALE: First/Last breeding dates:

Outcome:

Would you like us to update your primary veterinarian about your pet's reproductive visits with Gold Coast?

Would you like us to update your primary veterinarian about your pet's reproductive visits with Gold Coast?
A
B