Reproductive Form | The Pet Doctor

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?

Bitches Call Name

Patient DOB

What is the purpose of your visit today?

Has this bitch been bred before? *

Yes

If yes, complete the following:
1st:

Approximate Date:

Were progesterone tests done to detect time of ovulation? *

Yes

Was this a natural mating? *

Yes

If AI, what type of semen was used? (Check One) *

Fresh-Immediate

Fresh-Chilled

Frozen

Was Artificial insemination- (Check One) *

Vaginal

Transcervical

Surgical

Implant

Whelped? *

Yes

C-Section required? *

Yes

Number of Pups?

Number of Pups Survived?

2nd:

Approximate Date:

Were progesterone tests done to detect time of ovulation? *

Yes

Was this a natural mating? *

Yes

If AI, what type of semen was used? (Check One) *

Fresh-Immediate

Fresh-Chilled

Frozen

Was Artificial insemination- (Check One) *

Vaginal

Transcervical

Surgical

Implant

Whelped? *

Yes

C-Section required? *

Yes

Number of Pups?

Number of Pups Survived?

3rd:

Approximate Date:

Were progesterone tests done to detect time of ovulation? *

Yes

Was this a natural mating? *

Yes

If AI, what type of semen was used? (Check One) *

Fresh-Immediate

Fresh-Chilled

Frozen

Was Artificial insemination- (Check One) *

Vaginal

Transcervical

Surgical

Implant

Whelped? *

Yes

C-Section required? *

Yes

Number of Pups?

Number of Pups Survived?

4th:

Approximate Date:

Were progesterone tests done to detect time of ovulation? *

Yes

Was this a natural mating? *

Yes

If AI, what type of semen was used? (Check One) *

Fresh-Immediate

Fresh-Chilled

Frozen

Was Artificial insemination- (Check One) *

Vaginal

Transcervical

Surgical

Implant

Whelped? *

Yes

C-Section required? *

Yes

Number of Pups?

Number of Pups Survived?

5th:

Approximate Date:

Were progesterone tests done to detect time of ovulation? *

Yes

Was this a natural mating? *

Yes

If AI, what type of semen was used? (Check One) *

Fresh-Immediate

Fresh-Chilled

Frozen

Was Artificial insemination- (Check One) *

Vaginal

Transcervical

Surgical

Implant

Whelped? *

Yes

C-Section required? *

Yes

Number of Pups?

Number of Pups Survived?

Do you have reason to believe any of the above were pregnancies that resulted in miscarriage, abortion, or premature labor? If yes, explain:

Is this bitch in season now?

If yes, what day was the 1st day of vaginal bleeding?

When was your bitch’s thyroid level last evaluated?

What were the results?

Is your bitch taking any other medications, antibiotics, or supplements currently (including flea medication)?

When was the last time your bitch was dewormed, and with what product?

What food is your bitch currently eating?

Please describe any conditions which may affect your bitch’s fertility, including previous vaginal infections, vaginal rings or defects, other dogs in the household with contagious diseases, or other relevant information.

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