INITIAL HEALTH EVALUATION OF RESCUE SHIBA
Veterinary Hospital Name & Address :
Rescue Organization:__________________________________________________
Rescue Representative Name:___________________________________________
Address:_________________________
City:_____________________________
Phone:____________________________
Date of exam:______________,19___
Attending Veterinarian: (Please Print)____________________________________
Breed: _________________ Sex:___Neut?:_____Age:_____Height:____Weight:___
Breeder:_____________________________Tattoo # (if any):___________________
Microchip:______________________________
Findings of initial visit:________________________________________________
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Vaccinations anticipated:__________________________________________________
Worming program needed:___________________________________________________
Heartworm Medication needed:______________________________________________
Is this animal neutered?:________________Was this animal X-rayed?_________
If so, for what?__________________________________________________________
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Comments/Suggestions:_____________________________________________________
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Attending Veterinarian's Signature:_______________________________________
Thank you for your help and time. Please return this form to us at the
address below:
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