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Irish Wolfhound Seizure Study Dog Update
updated 23 October 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 #
Is This Dog Still Living?
Yes
No
Date of Death or Age at Death
if you don't know the exact date/age, please estimate.
Was the Dog Euthanized?
select one
Yes
No
Cause of Death
Medical History
Vaccination/Medication Information
Vaccination Detail
Heartworm Preventative Details
Flea and Tick Preventative Details
Seizure Medications (include dosages)
Other Medication Details (include dosages)
Seizure Information
Are seizures under control at this time (due to meds or other treatments)?
Frequency of Seizures
Seizure Occurrence
During sleep/rest
During the day
At night
Type of Seizure
Health Information
Other Health Issues
Other Information
Other Comments
Please Specify A Day and Time It's Best to Contact You by Phone
We may have additional questions concerning this update
