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Health Screening Registration

Please use this form to schedule and make a donation toward IWF health screening. Your donation helps defray the cost to the IWF for each test.

You will be contacted with your scheduled time, and if we need additional information.

If you have any questions, please email Frances Abrams at iwfhealth@gmail.com or call her at 937-371-3609.

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

Suggested Donations and Screening Test Type *

$200 - Echo/EKG/Auscultation (OFA form if requested) - 2-5 years

$100 - Echo, etc. - 6+ years and affecteds

$60 - EKG + auscultation - 2-5 years

$30 - EKG + auscultation - 6+ years

$20 - EKG only (no cardiologist visit)

Preferred Testing Time

We will try to accommodate your preference in scheduling.

Morning

Midday

Afternoon

Call Name

Registered Name

Registration Number

Date of Birth

(mm/dd/yyyy)

Gender

Male

Female

Spay/Neuter

Yes

Weight

Donation Amount

PLEASE ENTER PAYMENT INFORMATION ON THE NEXT SCREEN

Add 3% to my total amount to help cover the payment processing fees