Vet Reference Check Report

Date Reference Check Performed * Select the date the reference check was performed.
Your Full Name * Enter your first and last name.
Dobie's Name * Enter the name of the Dobie the adopter is interested in. If unknown, enter unknown.
Adopter Information
Adopter's First Name * Enter the adopter's first name.
Adopter's Last Name * Enter the Adopter's Last Name
Adopter's Phone Number * Enter the Adopter's phone number. Use format: xxx-xxx-xxxx
Veterinarian's Information
Veterinarian's Name and/or Clinic Name * Enter the Veterinarian's Name and/or the Clinic Name
Full Name of the person you spoke with at the Vet Clinic * Enter the full name of the person you spoke with at the Vet Clinic
Veterinarian's Phone Number * Enter the veterinarian's phone number. Use format xxx-xxx-xxxx
Vaccine Information
Is current dog(s) current on Rabies? * Is current dog(s) current on Rabies?
Is current dog(s) current on DHLPP/DA2PP? * Is current dog(s) current on DHLPP/DA2PP?
Is current dog(s) current on Corona Virus? * Is current dog(s) current on Corona Virus?
Is current dog(s) current on Bordetella? * Is current dog(s) current on Bordetella?
Heartworm Preventative Information
Is current dog(s) on Heartworm Preventative? * Is current dog(s) on Heartworm Preventative?
Which brand of Heartworm Preventative is used * You can select more than one, one at a time.
When was the last Heartworm test done? * Select the date when was the last Heartworm test done
When was Heartworm Preventative last purchased? * Enter the date when Heartworm Preventative was last purchased
General Questions
How long has (applicant's name) been a client of your clinic? * Enter the length of time the applicant has been a client of the vet clinic.
Are all current pets spayed or neutered? * Select yes or no.
Do the current pet(s) visit the vet at least once a year for a checkup? * Select yes or no
Has (applicant name) ever been in the clinic for an unusual injury? * Select yes or no
Are there any other animals (applicant name) has brought to your clinic in the past? * Select yes or no
Comments * Enter any additional 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 * Sign here
Signature Date * Enter today's date.
Click submit once. It may take up to 30 seconds for the screen to change. Do not click submit more than once.

Vet Reference Check Report

Adopter Information

Veterinarian's Information

Vaccine Information

Heartworm Preventative Information

General Questions

Signature