Blood Donor Intake - Metropolitan Veterinary Associates

This field is for validation purposes and should be left unchanged.

Qualifying Questions

Do you feel your dog/cat has a temperament to lay on his/her side for 10-15 minutes?*

Yes

Is your cat indoor only?*

Yes

Is your dog/cat currently on any medication outside of preventatives?*

Yes

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

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

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

Does your cat/dog take monthly heartworm and flea prevention?*

Yes

Brand names

Does your pet consume raw food?*

Yes

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

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

Has your pet ever had any medical or health problems/surgeries/diagnoses, even minor ones, in the past or currently?*

Yes

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

Does your pet have any food allergies/intolerances (after your pet has donated, we feed them to replenish nutrients)?*

Yes

Please list all allergies

Do you give MVA permission to use respectful photos of your pet for Blood Bank marketing purposes?*

Yes

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

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*

Signature*