Health Record Overview

Please complete, and make sure to click "Submit" at the end. This form is required before transport. Thank you!

Name of Dog

Rescue or Individual Responsible

Spay or Neuter?

Yes

Breed

Age of Dog in Years

Weight of Dog in Pounds

Current Food

Allergies / Other Notable Issues

Please enter "None" for no allergies or other notable issues

Rescue Date

YYYY

Vaccinations / Medications / Tests

Please Indicate Heartworm Status Upon Intake

Positive

Negative

Heartworm Test #1

Heartworm Test # 1 - Date

YYYY

Heartworm Test #1 - Result

Positive

Negative

Heartworm Test #2

Heartworm Test #2 - Date

YYYY

Heartworm Test #2 - Result

Positive

Negative

If the Dog Tested Positive for Heartworm, at Any Time, Please Let Us Know the Date the Treatment Started and the Date Treatment Ended

If Positive, Date Treatment Started

YYYY

If Positive, Date Treatment Ended

YYYY

Heartworm Preventative / Dosage

Date(s) Administered

Next Due Date

Flea and Tick Preventative/Dosage

Date(s) Administered

Next Due Date

Rabies Vaccination

Date(s) Administered

For puppies, please indicate date(s) of each round

Next Due Date

DHLPP

1st Round Date(s)

2nd Round Date(s)

3rd Round Date(s)

Adult Date(s)

Bordetella

Date(s) Administered

Next Due Date

Heartworm Test

Date(s) Administered

Fecal Test

Date(s) Administered

Dewormer

1st Round

Please indicate date of 1st Round and also when the 2nd Round is due

2nd Round

Please indicate date of 2nd Round and also when the 3rd Round is due

3rd Round

Adult Dewormer

Date(s) Administered

Microchip Number

PLEASE DON'T FORGET TO CLICK "SUBMIT" TO SEND YOUR COMPLETED FORM. THANK YOU!!