EmailMe Form - Save A Lab Vetting Information Form

Your Name *

First Last

Your Email Address

Include your email address if you need a copy of this form emailed to you

Name of Foster *

First Last

Foster Email Address

Include if you want a copy of the form emailed to the foster

Phone

### - ### - ####

Name of Dog *

Name of Litter

Approximate Age

Approximate Weight

Date of General Exam

MM / DD / YYYY

Rabies Vaccination Date

MM / DD / YYYY

Was this a 1 year or 3 year vaccine?

1 year

3 year

Rabies Tag #

Bordatella Vaccination Dates

MM / DD / YYYY

Distemper/Parvo Vaccination Dates

MM / DD / YYYY

Type of Distemper/Parvo Vaccine (Neopar, 5-in-1, etc.)

If distemper/parvo series is not completed please list the due date(s) for the next round of shots. This includes the full puppy series as well as the DHPP booster for adults.

Due Date(s) of Next Distemper/Parvo Vaccine

MM / DD / YYYY

Date of Heartworm Test

MM / DD / YYYY

Results of Heartworm Test

Was this a 4DX Test?

Yes

No

4DX Results

Lyme Positive

Erlychia Positive

Anaplasmosis Positive

Negative for All Tick Diseases

If dog has had a 4DX test, please record the results for tickborne diseases above - check all that apply.

Please list date(s) and result(s) of blood work. CBC and Chem 7 required if dog is 4DX positive (BEFORE dog is spayed/neutered or undergoes HW treatment or any other surgery).

Heartworm Prevention Dates

MM / DD / YYYY

List most recent dates first. Additional dates for HWP, dewormer and flea/tick can be included in the Notes section.

Type of Heartworm Prevention

Date of Last Heartworm Treatment Injection, if Dog was HW Positive

MM / DD / YYYY

Date of Last Fecal Test

MM / DD / YYYY

Results of Fecal Test

Please list any prior fecal tests - and results - here

Date of Last Giardia Test

MM / DD / YYYY

Results of Giardia Test

Please list any prior giardia tests - and results - here

Dewormer Dates

MM / DD / YYYY

Type of Dewormer

If a follow-up dewormer is needed for treatment, please list the due date here

MM / DD / YYYY

Flea/Tick Prevention Dates

MM / DD / YYYY

Type of Flea/Tick Prevention

Date of Spay/Neuter

MM / DD / YYYY

If already spayed/neutered at intake, check this box.

Yes

If your foster dog was spayed/neutered, and the sutures will need to be removed, please list the date here so that we can inform the next foster.

Date Suture Removal Needed

MM / DD / YYYY

Microchip Manufacturer

Microchip Number

Chip registration status

Unregistered

Registered by SAL

Already registered

Chip registration info

Name of SAL coordinator who registered the chip. Include the Microchip Provider if DIFFERENT from the Manufacturer listed above. If chip was registered prior to intake, include any known information here.

Please list any other pertinent information here, including all medications dispensed and any medical conditions that have been diagnosed/treated. Include dates and dosages as well.

Medical Notes

Any vetting documentation can be uploaded here:

File Upload