Breeding Information Breeding Information Today's Date * Your Name * Your Name First Name First Name Last Name Last Name Phone Number * Email * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Pet's Name * Your Pet's Name Breed * Please tell us the pet's breed Pet's Date of Birth (or best estimate if uncertain) * First day of most recent heat cycle * Has your pet been bred before? * Yes No If yes, did she have a litter? * Yes No How many litters has she had? * Zero One Two Three Four Five More than Five If she has had litters in the past, did she: Free Whelp Have a C-Section performed If there have been previous complications with breedings or delivery, please describe. If there have been no previous complications, please type 'none'. Does your bitch need a Brucella test? * Yes No Brucella is an infection that is spread by any bodily fluid (including semen, saliva and blood) and can cause the aborting of the litter. We recommend a Brucella test every cycle. Is your pet on heartworm prevention? * Yes No If yes, what kind? Is your pet on flea/tick prevention? * Yes No If yes, what kind? Please list any and all medications or supplements your pet is taking. * Please list ALL medications or supplements What is your pet's current diet? * Where will this breeding take place? * Highland Pet Hospital A location outside of Highland Pet Hospital How will she be bred this cycle? * Natural Breeding Vaginal Artificial Insemination Transcervical Insemination What type of semen will be used? * Fresh Semen Cool Shipped Frozen What is the stud dog's name? Who is the owner of the stud? Who is the owner of the stud? First Name First Name Last Name Last Name Stud owner's Phone Number State/Location of Stud AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Other/Previous veterinary provider- we will require proof of vaccination status HPH requires both of the following for all breeding patients: Proof of current/up to date vaccination records and a copy of the patient's registration certificate. We can accept .jpg or .pdf file formats. Drop a file here or click to upload Choose File Maximum file size: 52.43MB Registration & vaccine records Required documents- I attest that * I have attached my vaccine and registration documents as requested above. My registration and vaccines are on file and have been confirmed with an HPH team member Thank you for completing the breeding information form. This will save you time during your pet's appointment at Highland Pet Hospital. We look forward to serving you and your pet! Date * Captcha Submit If you are human, leave this field blank.
