Client Information

Owner’s Name: *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

E-mail *

Patient Information:

Pet’s Name: *

Breed:

Colour:

Date of Birth:

Weight:

Sex *

Male
Female

Male Name *

Has any testing been done? (OFA - hips, eyes, elbows, thyroid, etc. PennHIP, genetic testing, etc.)

Previous Breeding Use

Yes
No

Previous Litters

Yes
No

Number of Puppies in Litters

Issues with Puppies in Litters

Yes
No

Please Specify

Drive (Energy level, motivation)

Shy in new environments with new people

Yes
No

Travel to dog shows

Yes
No

Brucellosis Test Completed

Yes
No

Ever Been Collected From for Semen

Yes
No

Semen Evaluated?

Yes
No

Signs of Fear or Anxiety

Yes
No

Medical Issues

Behavioral Concerns

Female Name *

How many heat cycles has she had?

Regular Interval/Consistent Timing for Heat Cycles

Has any testing been done? (OFA - hips, eyes, elbows, thyroid, etc. PennHIP, genetic testing, etc.)

Any abnormal nipples, vulva, or vagina noted

Yes
No

Please Specify

Previous Breeding Use

Yes
No

Breeding Method Used - (natural, chilled, frozen?)

Previous Litters

Yes
No

Number of Puppies in Litters

Issues with Puppies in Litters

Yes
No

Please Specify

Any issues with whelping?

Yes
No

Any need for c-section in the past?

Yes
No

Travel to dog shows?

Yes
No

Brucellosis Test Completed

Yes
No

Does she show any signs of fear or anxiety?

Yes
No

Medical Issues

Behavioral Concerns

Referring Veterinary Clinic:

Referring Veterinarian:

Patient History

Vaccine History: (Vaccine given, good until – eg: Rabies, January 1, 2022)

Purpose for Reproduction Referral

Health History: (Please list any health or behavioural concerns, as well as any relevant testing)

Referral Form Canine Reproduction