Male Reproductive Form

Please fill out this form before 48 hours before your appointment

Your Name *

Your Phone *

Do you authorize us to send text messages to this phone number?

Have you or anyone in your household tested positive for Covid-19 in the last 14 days or been exposed to someone who has?

Have you experienced unexplained coughing, fever, aching, loss of sense of smell or taste, and/or sore throat, in the past 14 days?

Co-Owner’s Name

Co-Owner’s Phone Number

Do you want us to release information about your exam or subsequent test to the Co-owner or any other individual connected with this mating?

Dogs Call Name

Patient DOB

What is the purpose of your visit today?

Has this dog been bred before? *

Yes

If yes, complete the following:

Has this dog been bred before?

How many of these breedings have resulted in a litter?

Have litter sizes been unusually small for your breed?

When was the last time your dog was mated or semen collected?

When was the last time he produced a litter?

Has your dog been bred naturally?

Fresh artificial insemination?

Chilled artificial insemination?

Is frozen semen stored on this dog?

If so, with what semen bank?

Has your dog’s semen been evaluated?

If so, please give the date and email results if available to: [email protected]

When was your dog’s thyroid last evaluated?

What were the results?

Is he now on thyroid supplementation?

Is your dog taking any other medications, antibiotics, or supplements?

If so, please list them:

Please describe any conditions that may affect your male’s fertility or our ability to collect semen such as; shyness, aggression, previous penile or testicular injuries, or previously diagnosed infections.

Payment & Service Policies Payment in full is due at the time of service (at each visit). We are unable to carry balances through a breeding cycle. If you have questions regarding our pricing and services, please inquire prior to receipt of services. Responsibility for payment is ultimately held by the account holder. If another person is to pay for services, they must call in and provide credit card information prior to services being rendered. Emergency reproductive services may be available on a case-by-case basis for additional fees. No guarantee of emergency service availability is made. It is up to each owner to have a back-up plan. A reproductive consultation is included in the care plan of each breeding cycle and is not optional. Please type your name to indicate that you have read, understood, and accept the terms of the statement above:

Signature *

Monday	8:00 am	6:00 pm
Tuesday	8:00 am	6:00 pm
Wednesday	8:00 am	6:00 pm
Thursday	8:00 am	6:00 pm
Friday	8:00 am	6:00 pm
Saturday	CLOSED	CLOSED
Sunday	CLOSED	CLOSED