Great Dog Rescue New England Medical Summary Sheet

Sending Rescue:

Filled out by:

First Name

Last Name

Phone:

(###)

###

####

Dogs Name:

Breed:

Color:

Age / Weight:

Sex:

Male

Female

Altered:

(Certificate/Proof must be enclosed)

Yes

If yes, date:

YYYY

Vaccinations

Rabies (for dogs 12 weeks and up):

(Rabies certificate must be enclosed)

YYYY

Puppy: (DA2PPv, DHPP, DHLPP) up to 4 months

Puppy 1

YYYY

Puppy 2

YYYY

Puppy 3

YYYY

Adult Dog: (DA2PPv, DHPP, DHLPP) 4 months+

Adult Dog

YYYY

Bordetella

(MUST be given at least 10 days prior to transport)

YYYY

Testing

4DX Test:

YYYY

HW, Ehrlichia, Lyme, Anaplasmosis Results:

Fecal: (Date and Result)

Preventatives

Heartworm:

YYYY

Flea & Tick:

YYYY

Albon/Marquis/Other:

YYYY

Dewormer:

YYYY

Any Special Notes?

i.e. old injuries, personality, quirks, special needs