Vet Reference Check Report

Date Reference Check Performed *

Your Full Name *

Dobie's Name *

Adopter Information

Adopter's First Name *

Adopter's Last Name *

Adopter's Phone Number *

Veterinarian's Information

Veterinarian's Name and/or Clinic Name *

Full Name of the person you spoke with at the Vet Clinic *

Veterinarian's Phone Number *

Vaccine Information

Is current dog(s) current on Rabies? *

Is current dog(s) current on DHLPP/DA2PP? *

Is current dog(s) current on Corona Virus? *

Is current dog(s) current on Bordetella? *

Heartworm Preventative Information

Is current dog(s) on Heartworm Preventative? *

Which brand of Heartworm Preventative is used *

When was the last Heartworm test done? *

When was Heartworm Preventative last purchased? *

General Questions

How long has (applicant's name) been a client of your clinic? *

Are all current pets spayed or neutered? *

Do the current pet(s) visit the vet at least once a year for a checkup? *

Has (applicant name) ever been in the clinic for an unusual injury? *

Are there any other animals (applicant name) has brought to your clinic in the past? *

Comments *

Signature

I certify that I contacted the veterinarian's office described above and I spoke with a representative of that office. I further certify that the above information is true and correct.

If you are using a phone or tablet to complete this application, simply sign your name below. If you are using a computer, use your mouse to write your name below.

Signature *

Signature Date *

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