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Theriogenology Intake Form

Pet Name:

Client Name:

Co-owner:

Pet's Registered Name:

AKC Reg. Number:

Microchip#:

DNA Completed:

A
B

Date of last Brucellosis screening:

Test Run:

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

Day this heat cycle began:

Artificial Insemination being performed at our clinic?

A
B

Date of last heat cycle:

Reason for Visit:

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?

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):

A
B

Date of last heartworm test and result:

PREVIOUS BREEDING HISTORY: IF APPLICABLE

FEMALE: First breeding/ Previously bred on:

Outcome:

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?

A
B