The Irish Wolfhound Foundation

Owner Information

Name

*

First Name

Last Name

Email

*

Verify Email

*

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Home Phone

Cell Phone

VPC Study Entry Information

I understand that the participation of my dog in this study is voluntary and will be used for research by the Irish Wolfhound Foundation. I understand that I may be asked for additional information and testing that relates to this study (at IWF expense) and agree to provide information on my dog’s health, if possible.

I agree to release the results of the testing to the IWF. I understand that the identity of the dog and owner will not be used in publications but that other information (i.e. age, sex, other ailments or medications) pertinent to the study may be used.

I agree to hold the Irish Wolfhound Foundation and their officers, members and agents, and all employees harmless from any claim for loss or injury which may be alleged to be caused directly or indirectly to any person or dog involved in the testing.

I understand that the testing in this study is for data collection and that, although I may use the results to provide information to any veterinarian treating my dog, the Irish Wolfhound Foundation is not obligated to recommend or provide any treatment.

I consent to have my contact information released to IWF supported researchers so they can directly contact me for more detailed information.

*

Yes

No

Signature

*

By checking this box you are electronically signing this form and agreeing to the study entry conditions specified above:

I agree

The IWF will provide you with acknowledgement of your entry and instructions for receiving reimbursement for veterinary care required by the study.

Dog General Information

Call Name

*

Registered Name

Registration #

Weight in Lbs

Date of Birth

(mm/dd/yyyy)

Gender

Spay/Neuter?

Dog Medical Information

Does your dog have any medical problems?

Medical Problem Details

Please list any medications your dog is taking:

Please list any heartworm and flea/tick medications your dog is taking:

Main Diet

Diet Details

Please describe your dog's diet. If feeding kibble, canned or commercial raw, include brand, name and life stage (e.g., all ages, senior), breed (e.g., all breeds, large breed, hound) and flavor if not included in name.

Please list any dietary supplements or vitamins your dog is taking:

Primary Care Veterinarian Information

Veterinarian's Name

First Name

Last Name

Veterinarian's Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Veterinarian's Email

Verify Email

Veterinarian's Phone

Veterinarian's Fax

Veterinary Cardiologist Information

Cardiologist Name

First Name

Last Name

Cardiologist Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Cardiologist Email

Verify Email

Cardiologist Phone

Cardiologist Fax

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