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Irish Wolfhound Seizure Study Control Dog Enrollment
updated 03 November 2021
Owner Information
Name
*
First Name
Last Name
Email
*
Verify Email
*
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Phone
Dog General Information
Call Name
*
Registered Name
Registration #
Date of Birth
(mm/dd/yyyy)
Gender
select one
Female
Male
Spay/Neuter?
select one
No
Yes
Sire's Registered Name
Dam's Registered Name
Number of Pups in Litter
Dog Housing:
House
Kennel
Dog Diet Information
Main Diet
Select the diet type that best describes the majority of your dog's diet
select one
Raw commercially-formulated
Raw Pre-mix Commercial
Raw Home-prepared
Cooked Home-prepared
Kibble
Canned
Other
Diet Details
Please include brands for commercial diets
Medical History
Vaccination/Medication Information
DHLP/Parvo Given:
in combination
separately
DHLP/Parvo Interval Given
Heartworm Preventative Details
Flea and Tick Preventative Details
Other Medication Details (include dosages)
Other Information
Other Health Issues
Veterinarian Name and Contact Information
Temperament Description
Other Comments
