Blood Bank Donor Registration Form - BluePearl Pet Hospital

Personal Information

Your name

First Last

Phone

Preferred method of contact

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please select your local BluePearl blood bank location.

How did you hear about BluePearl Pet Blood Bank?

Donor Information

Pet's name

Date of birth

Must be 1-8 years old

Species

Cat

Dog

Breed(s)

Color(s)

Weight (in lbs.)

Sex

Female

Male

Spayed/neutered

Yes

Primary care veterinarian

Date of pet’s last vaccine - Rabies

Date of pet’s last vaccine - DHPP

Date of pet’s last vaccine - FVRCP

Date of last FeLV/FIV test

Other vaccines (if applicable)

Has your pet had a fecal test?

Yes

Date of last fecal test

What is your pet's current diet?

Does your pet have any food allergies?

Are there any other pets in your household?

Please include their species, breed, age, and spay/neuter status.

Is your pet in good general health?

Yes

Is your pet taking any medications?

Yes

Please list medications (Including supplements)

Is your pet taking heartworm/tick preventative year-round?

Yes

Please list heartworm and flea/tick medication

Date of last heartworm and tick screening

Is your pet comfortable being handled by strangers and able to stay calm for a period of time?

Yes

Is your cat indoor only?

Yes

Please describe your pet's temperament

Has your pet traveled with you?

Yes

Where have you traveled?

Has your pet previously received a blood or plasma transfusion?

Yes

Has your pet had surgery or been hospitalized other than spay, neuter or dental?

Yes

Please describe hospitalization/surgery

Please select any of the following medical conditions your pet has been diagnosed with

Other condition - please list here

Are you willing to commit your pet to at least four donations a year?

Yes

Are you comfortable with a 2-4" area of hair being removed from your pet's neck at each donation?

Yes

Are you comfortable with your pet being sedated for donation?

Yes

Are you available to have your pet donate blood anytime?

Yes

Please list your availability

Consent for Services

Consent for Euthanasia: As owner or authorized agent for the pet described hereon, I hereby give consent for euthanasia services. I further authorize BluePearl Pet Hospice to care for the handling of my pet's cremation, if elected, through our partner crematorium. To the best of my knowledge and belief, this pet has not bitten any person during the last 15 days.

Records and Communication Policy

BluePearl Specialty and Emergency Pet Hospital is part of your pet’s continuum of care, and we may provide your family veterinarian, any specialists, and/or a reviewing body information regarding your pet’s treatment and/or condition. By signing below, you are authorizing BluePearl Specialty and Emergency Pet Hospital to share your pet’s medical record with a third party (such as your family veterinarian) or its agent necessary for us to provide continuous veterinary care to your pet. You agree that we (or our agents) may send you communications to your contact information provided above regarding your pet.

Client Signature*

Date*

Data Privacy Notice

BluePearl and our affiliated entities are committed to providing quality and informed services to and for you and your pet. We aim to be your partner in your pet's long-term health and happiness through a variety of means, including by considering research, diagnosis and analysis from across our vet hospitals and brands. As part of this mission, we work with our affiliates, parent and subsidiaries to provide the services you request and to analyze and evaluate the patterns of diagnosis and treatment of the pets treated at our facilities. From time to time we, BluePearl, and our affiliates, may also use the data collected from you and your pet for research and for advertising and promotion of goods and services that may be of interest and beneficial to you and your pet. For more information on our policies and information on how to opt-out of some forms of sharing, please see our Privacy Policy at https://www.mars.com/privacy.

CAPTCHA

Pet Blood Donor Registration