The Irish Wolfhound Foundation · Health Screening Registration Without Screening Donation (No Payment)

Owner Contact Information

Please note all contact information is required.

Name

*

First Name

Last Name

Email

*

Verify Email

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone

*

cell phone preferred so we can contact you at the event site

Testing Information

Heart Test Type

Echo/EKG/Auscultation (OFA form if requested) - 2 years and older

EKG/Auscultation

EKG Only (no cardiologist visit)

Specialty Show/Event

*

Please indicate which show or event you are scheduling screening for.

Screening Day

This show has multiple testing days for heart screening. Please select your preferred day.

Wednesday 4/19 (only EKGs available in the morning)

Thursday 4/20

Preferred Testing Time

We will try to accommodate your preference in scheduling.

Morning

Midday

Afternoon

DOG INFORMATION

Please fill out one set of questions for each dog to be tested.

Call Name

Registered Name

Registration Number

Date of Birth

(mm/dd/yyyy)

Gender

Male

Female

Spay/Neuter

No

Yes

Weight