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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

Yes

B

No

Date of last Brucellosis screening:

*

Test Run:

*

Test Run:

RSAT

Culture

AGID

PCR

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

Yes

B

No

Plan to use:

*

Plan to use:

Natural

Fresh AI

Fresh Chilled AI

Vaginal

TCI

Surgical

Date of last heat cycle:

Reason for Visit:

Health screening performed:

*

Health screening performed:

A

Yes

B

No

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

Yes

B

No

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

Yes

B

No

Date of last heartworm test and result:

PREVIOUS BREEDING HISTORY: IF APPLICABLE

FEMALE: First breeding/ Previously bred on:

Outcome:

Timing:

None

Male

Vag cyt

Progesterone

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

Yes

B

No