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Blood Donor Intake

Please take the time to fill out this blood donor intake form and questionnaire so that we can confirm the eligibility of your pet.

Qualifying Questions
Do you feel your dog/cat has a temperament to lay on his/her side for 10-15 minutes?*
- Yes
- No
Is your cat indoor only?*
- Yes
- No
Is your dog/cat currently on any medication outside of preventatives?*
- Yes
- No
If you answered yes to this question, unfortunately, your pet is not eligible to be a blood donor. If they are on any medications for any issue then they are not considered "healthy" by donor standards. This is to protect the donor from having any stress put on their bodies to make any issues they have worse.
Is your dog/cat up to date on vaccinations?*
- Yes
- No
If you answered no to this question, unfortunately, your pet is not eligible to be a blood donor.
- Rabies
- Distemper/Parvo
- FVRCP
- Bordetella
- Canine Influenza
May we contact your local veterinarian for your pets' medical records if needed?*
- Yes
- No
Please note your primary veterinarian's practice name
Are you willing to bring your pet in for blood donation every 12 weeks if needed?*
- Yes
- No
Does your cat/dog take monthly heartworm and flea prevention?*
- Yes
- No
Brand names
Does your pet consume raw food?*
- Yes
- No
If you answered yes to this question, unfortunately, your pet is not eligible to be a blood donor.
Has your pet ever had a blood transfusion?*
- Yes
- No
If you answered yes to this question, unfortunately, your pet is not eligible to be a blood donor.
Has your pet ever been diagnosed with a heart murmur?*
- Yes
- No
Has your pet ever had any medical or health problems/surgeries/diagnoses, even minor ones, in the past or currently?*
- Yes
- No
Medical or health problems/surgeries/diagnoses
Are you comfortable with an area of hair being clipped from your pet’s neck (clipping is a necessary procedure to aseptically prepare the area for blood collection)?*
- Yes
- No
Does your pet have any food allergies/intolerances (after your pet has donated, we feed them to replenish nutrients)?*
- Yes
- No
Please list all allergies
Do you give MVA permission to use respectful photos of your pet for Blood Bank marketing purposes?*
- Yes
- No
We really appreciate you giving your time and offering your pet to be a donor and help save some lives. We are sorry if any of the questions mean that your dog/cat is not suitable to be a donor. This is to protect the recipients from any harm due to a transfusion as well as limit any risk to your own pet that may come from taking blood.
To continue interest in our Blood Bank program, and to see if your pet is eligible, please continue filling out the information below.
- Pet Parent Information
- Pet Parent's Name*
- Address*
  Street Address Address Line 2 City State ZIP Code
- - Primary Phone*
- - Alternate Phone
- Email*
- Donor Information
- Pet's Name*
- - Species*
- - Breed*
- - Gender
- - Current Weight*
- - Date of Birth/Age*
- - Color
- Pet Spayed/Neutered?*
  - Yes
  - No
Authorization to Treat
Initial Screening: I, the undersigned owner of the above pet, give permission for the doctor(s) and staff to perform an initial exam of my pet and collect lab specimens to determine if my pet is an eligible blood donor. I understand that there is no fee incurred today. If there are any abnormal findings that prevent my pet from becoming a blood donor, I understand it is my responsibility to follow up with my regular veterinarian and incur any charges for further diagnostics or treatment.
- Initial
Blood Donation: I, the undersigned owner of the above pet, give permission for the doctor(s) and staff to collect blood from my pet today for donation. I have been advised to the nature of the procedures and the potential risks. I understand that after the procedure and for the rest of the day, I can expect my pet to be groggy, tired, have a shaved area, and/or potential bruise of area.
- Initial
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2626 Van Buren Avenue
Norristown, PA 19403
Phone: 610-666-1050
Email: info@Metro-Vet.com
Fax: 610-666-1199

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