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Reproduction History Form

Name

Owner First Name

Owner Last Name

Mobile Phone *

Email *

Enter email address

Patient Name *

Date she started bleeding?

Has she had a brucellosis test done?

Yes

No

If yes, when and where? What were the results?

If no, would you like to brucellosis test?

Will the breeding be done at AVC?

Yes

No

Please select which insemination method you plan to use?

Surgical A/I

Vaginal A/I

Free Stand

Are you having semen shipped?

Yes

No

If yes, will the semen be

Frozen

Fresh

Chilled

Where is the male located?

Will you be confirming the pregnancy via ultrasound at AVC?

Yes

No

Which of the following whelping methods do you plan to use?

Free whelp

Planned C-section

If you are doing a C-section, will that be done here at AVC?

Yes

No

When was her first heat cycle?

How many heat cycles has she had?

Has she been bred before?

Yes

No

Date of her last breeding

Did she carry full term and deliver puppies?

Yes

No

How did she whelp?

Free whelp

Planned C-section

How many puppies were in the litter? How many survived?

By checking this box and/or signing below, I acknowledge that Angleton Veterinary Clinic has a "No Staff Abuse" policy in place and they will not tolerate abuse of any kind towards staff, including verbal abuse. The abuse statement can be found below: "Our staff work hard during an often difficult and worrying time to provide you and your pet the best care. As such, we will not tolerate any rudeness or abuse towards any staff members. We appreciate your care for our family as we care for yours."

By checking this box, I certify that I am the owner/agent of the above described animal. I accept full financial responsiblity for this animal and have the authority to execute consent to any procedures necessary.

Date

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