EVBB Donor Form


OWNER INFORMATION

Owner Name:



Home Address:

City/State/Zip:

Home Telephone:

E-mail Address:

Work Telephone:

Regular Veterinarian:

Vet's Telephone:

Vet's Address:

DONOR INFORMATION

Donation Site:

Dog's Name:

Breed(s):

Description:

Sex: Male(intact)Yes   Male(castrated)   Female(intact)   Female(spayed)

Approximate Birthday:
Month:    Year:

How old was this dog when he/she joined your family?

Approximate Dates of Last Vaccinations:
Distemper & Parvo: Rabies:

Approximate Date of Last Heartworm Test

During which months is your dog given heartworm preventative?

Is your dog currently healthy? Yes   No

Does your dog take any medications? Always   Sometimes   No

Please list medications:

Has your dog had any health problems in the past?Skin or Eyes Yes No

Muscle or Bone Yes No

Heart or Lung Yes No

Lumps or Bumps Yes No

Kidney or Liver Yes No

Stomach or Intestinal Yes No

If yes, please explain.

Has your dog ever received a blood or plasma transfusion for any reason? Yes No

If yes, please explain.

Has your dog ever been pregnant? Yes No

Has your dog ever shown any signs of aggression toward people?
Yes No

If yes, please explain.

Has your dog ever shown any signs of aggression toward other dogs?
Yes No
If yes, please explain.

Has your dog traveled or lived outised the Mid-Atlantic region?
Yes No
If yes, please explain.

How did you hear about the Eastern Veterinary Blood Bank?

Which of our blood drive locations would be most convenient for you? (You are always free to switch to a different location.)

MARYLAND
Severna Park - Eastern Veterinary Blood Bank home
Baltimore - Rosedale Animal Hospital
Bel Air - PetSmart (Banfield, The Pet Hospital)
Bethesda - Kenwood Animal Hospital
Bowie - Animal Clinic of North Bowie
Bowie - Highway Veterinary Hospital
Cambridge - Bayside Animal Hospital
College Park - College Park Animal Hospital
Columbia - Lewis Veterinary Hospital
Crofton - Crofton Veterinary Center
Easton - Community Animal Hospital of Easton, LLC
Funkstown/Hagerstown - Animal Health Clinic of Funkstown
Frederick - Kingsbrook Animal Hospital
Jefferson - Jefferson Veterinary Hospital
Monkton - Mt. Carmel Animal Hospital
Prince Frederick - Canine Mind
Salisbury - Winter Place Veterinary Hospital
Sandy Spring - Olney Sandy Spring Veterinary Hospital
Severn - Telegraph Road Animal Hospital
Timonium - Timonium Animal Hospital
Westminister - Airpark Animal Hospital
West River - Muddy Creek Animal Hospital
VIRGINIA
Arlington - Fur-Get Me Not Pet Care
Centreville - Centreville Animal Hospital
Fairfax - Pender Veterinary Clinic
Fairfax - Webers Pet Supermarket
Great Falls - Great Falls Animal Hospital
Herndon - Herndon Animal Medical Center
Leesburg - Dog Day Afternoon
Springfield - Olde Towne Pet Resort
Sterling - Animal Medical Center of Cascades
WEST VIRGINIA
Charles Town - Briggs Animal Adoption Center
*Please note that some medications may prevent your dog from donating. Please contact us for details prior to scheduling an appointment.
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