Auburn College of Veterinary Medicine Blood Bank Auburn Vet Med Blood Donor Questionnaire Owner InformationOwner(Required) First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) How do you know us?(Required) AUCVM Faculty AUCVM Staff AUCVM Student Community Member Class year if you're a student:(Required)Not a Student1st Year Student2nd Year Student3rd Year Student4th Year StudentPet InformationPet Name(Required) First Sex(Required) Male Female Spayed/ Neutered?(Required)All canine volunteers must be spayed or neutered. Spayed Neutered BreedWeight(Required)All canine volunteers must be 50 lbs or more to participate.DOB/ Approx. Age(Required)Canine volunteers must be 1-6 years of age.QuestionnaireAre you able to drop your pet off 6 times a year for a blood draw?(Required) Yes No Will you be in Auburn for the next 2 years?(Required) Yes No Would your pet allow for blood draws without chemical restraint?(Required) Yes No Do you foster other animals awaiting adoption?(Required) Yes No May we shave your pet’s neck to obtain clean blood draw?(Required) Yes No Is your dog on a raw diet?(Required) Yes No Is your dog itchy or has your dog had recurrent ear infections?(Required) Yes No Has your pet ever been pregnant?(Required) Yes No Does your dog have a spleen?(Required) Yes No Has your pet had or been treated for heartworms?(Required) Yes No Does your pet receive monthly heartworm preventative?(Required) Yes No What type of preventative?(Required)Has your pet ever received any type of blood products?(Required) Yes No Has your dog ever been diagnosed with vector borne pathogens?(Required)(Erhilichiosis, Rocky Mountain Spotted Fever, Babesiosis, or Lyme Disease) Yes No Other than a spay or neuter, has your pet had any other surgeries?(Required) Yes No What other surgeries have your pet had.(Required)Is your pet on flea and tick preventative?(Required) Yes No Is your dog currently on any other medications?(Required)(Anything other than HW or flea and tick preventative) Yes No Please list other medications(Required)Please provide dates for the following:(Required)Donors must be in good health and current on vaccinations.RabiesDA2PHeartworm Test Add Remove
