Canine Blood Donor Screening Questionnaire

Canine Donor's Information

Name:

Breed:

Age: (Must be 1-6 years old)

Sex:

Weight: (Must be over 55 lbs)

Has your dog previously received a blood transfusion?

Is your dog comfortable being handled by strangers and able to stay calm for a period of time?

Is your dog in good general health?

Please explain:

Is your dog on preventatives for flea/tick and heartworm?

Is your dog up to date on all vaccinations?

Does your dog take any medications?
Medications besides preventatives disqualify your pet from participating in our blood donor program.

Canine blood donor participants should plan for a one-year commitment in the BEVS Blood Bank Program. Are you willing to commit to four scheduled visits a year to the BEVS Blood Bank Program for your dog to provide donations?


Thank you for completing our questionnaire. Please let us know how to reach you with the status of your dog's eligibility for the BEVS Blood Bank Program. We will be in touch within two weeks of receipt.

Client's Information

Name:

Phone:

Address:

E-mail Address: