Veterinary Backend
Vet Registration # _______________________
Vet Office Name _______________________
Veterinarian Name _______________________
Date _________________
Canine Microchip # ___________________
Canine Breed ___________________
Call Name _____________________
Registered Name ______________________
AKC Registration # _________________
Owner Name ______________________
Owner Email _____________________________
Owner Address ____________________________________________________
Owner Phone ______________________
Sire (Father) Name _______________________
Sire Microchip # _______________________
Dam (Mother) Name _______________________
Dam Microchip # _______________________
DOB _____________
DOD ______________
Cause of Death ______________
Could Cause of Death Be Hereditary ______________
DNA _________________ (Upload File)
OFA Results ___________ (Upload File)
Current Weight ______________
Canine Is: Overweight ____ Underweight ____ Healthy Weight _____
Coat Type __________
Coat Color __________
Height at Shoulder in Inches __________
Annual Repro Exam Completed __________
Repro Exam Pass/Fail __________
Has Canine Been Diagnosed With an Illness That Could Be Hereditary __________
If Yes, What is Illness? __________________________________________________________