Planned Breeding Worksheet
Bitch Call Name:
Were you referred to us?
If Yes, Referring/Regular Veterinarian:
Will you be performing part of the ovulation timing elsewhere?
If Yes do they use Idexx laboratory?
Previous Medical Problems:
Current Diet, Medications & Supplements (including Heartworm & Flea/Tick preventatives):
Recent Snap 4DX Heartworm & Tick screen testing date & result:
Recent Blood Work?
(Please note: CBC & Blood Chemistry are required for any procedure involving sedation/anesthesia, i.e., surgical insemination, for the safety of your bitch.)
Are you planning to board your bitch at Slade Veterinary Hospital, Inc. during breeding?
Vaccination History (current vaccination certificates required for boarding) Proof ofRabies vaccination & Brucellosis test required for all procedures
Rabies Vaccination Date Given:
Distemper, Adenovirus-2, Parvovirus (DA2P) Date Given:
Parainfluenza Virus Date Given:
Bordetella Date Given:
Influenza Date Given:
Previous Breedings? Please list and include dates of matings performed (including type of semen used such as natural mating/fresh collect/ship-chilled/frozen), ovulation timing performed (if any), and if the breeding was successful including # of puppies and any problems with labor & delivery (whelping):
Current Breeding Plan
Date First in Season:
Plan for Whelping:
Brucella Canis Test Date:
(Please bring a copy of certificate of negative test within past 90 days)
Type of Breeding:
Type of Semen Being Used:
Number of Breedings/Inseminations Available/Planned:
Stud Dog Information
Stud Dog Name:
Brucellosis Test Date:
Stud Dog Owner:
Stud Dog Collecting Veterinarian:
Multiple Sire Breeding?
Stud Dog #2 Name:
Brucellosis Test Date:
Stud Dog #2 Owner:
For bitches with multiple owners, please list the primary contact person authorized to make all breeding related decisions, understanding that this is the ONLY person who will be contacted by our staff in an effort to streamline all decisions and avoid any miscommunications.
Primary Contact Name:
I authorize Slade Veterinary Hospital, Inc. to release reproductive information of the above described dog, including breeding/ovulation timing results, to the stud dog owner and stud dog owner’s veterinarian as listed above:
I UNDERSTAND THAT WITH ANY BREEDING PROCEDURE, THERE IS NO GUARANTEE OF CONCEPTION.