MedIntakeForm | K9 Kavalry

MEDical intake form

canine medical survey

SECTION 1: Team Stats

Your First Name

Your Last Name

Dog's Name

Dog's Current Age

Dog's Sex

Male

Female

Dog's Breed

Dog's Current Weight

Spayed or Nuetered?

Yes

Dog's DOB

Dogs's color(s) and/or markings

SECTION 2: Vaccinations

Enter the most recent immunization date for each vaccination below

DHPP

Rabies

Leptospirosis

Coronavirus

Parvo

Distemper (on it's own)

Bordatella

Influenza (on it's own)

Lyme Disease

Measels

If available, upload current shot records here

Image files only max 15mb

Examine this chart...

Then click here.

I accept the terms & conditions listed in this chart and agree to maintain accurate immunization records with K9K for the duration of my program enrollment.

SECTION 3: Veterinarian Details

Enter the most recent immunization date for each vaccination below

Veterinarian Office Name

Veterinarian Phone Number

Insurance Policy Number

Veterinarian Website

SECTION 4: Medical History

Enter as much information as you can regarding your dog's health history

Please list all medications your dog is taking

Please list any allergies your dogs have

Please list all conditions your dog is currently being treated for.

Please list any major injuries or seizure indicents, with dates.

SECTION 4: Emergency Contact Information

Help us help you in the event of an emergency

Emergency Contact NAME

Emergency Contact PHONE

If you are hospitalized, can your emergency contact care for your dog?

Yes

THAT'S IT! ALWAYS REMEMBER, PACK GOT YOUR BACK