Reproduction DVM Referral Form

Date

YYYY

Referring Veterinarian

First Name

Last Name

Clinic Name

Clinic Phone

(###)

###

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Clinic/DVM Email

Reason for Reproduction Referral

Client Info

Client Name

First Name

Last Name

Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Phone (Cell)

(###)

###

####

Client Phone (Other)

(###)

###

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Patient Info

Patient Name

Breed

Sex

Date of Birth

YYYY

Patient History

General Health History

Please list any health or behavioural concerns and any medications.

Relevant Health Testing

Please note any relevant health testing (eg. PennHIP, OFA, genetic testing, EMBARK, burcellosis, etc.)

Reproductive History

If FEMALE: Any previous breeding attempts?

Please include semen used (fresh, chilled, frozen), method of insemination, if progesterone timing was used, and the outcome of the breeding.

Any issues with whelping?

C-section needed? Milk production issues?

If MALE: Any previous breeding attempts?

Include successes and misses. Has a semen evaluation been completed previously?