Veterinary Medical Evaluation
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1
2THE GOOD DOG FOUNDATION
VETERINARY MEDICAL EVALUATION
Good Dog requires an annual veterinary exam reported on this Good Dog veterinary form for every
certified Good Dog. An updated veterinary report must be turned in within 12 months from the date of
the last veterinary report. Please call the Good Dog office at (888) 859-9992 if your veterinarian has any
questions about completing this report.
Owner’s Name: _________________________________________________________
Mailing address: _________________________________________________________
_____________________________________________________________________
Phone: Home: _____________________ Cell: ________________________________
Fax: ___________________________ E-mail: _________________________________
Pet’s name: _________________________ Breed: _____________________________
Date of birth: ____________ Male_____
Female____ Spayed/Neutered _________
Weight: __________________
Coat color: _________________________________
Veterinary Clinic: ________________________________________________________
Mailing address: _________________________________________________________
_____________________________________________________________________
Phone: __________________________ Fax: __________________________________
Attending veterinarian: ___________________________________________________
The Good Dog Foundation complies with state laws regarding vaccinations. We understand that this
animal’s veterinarian is in the best position to prescribe other vaccinations or titers that will ensure the
animal’s immunity and safety in a health care facility and will ensure client health and safety.
Vaccination:
Expiration Date
Rabies (State Law):
______________________
Other (Please list):
________________
______________________
________________
______________________
________________
______________________
The Good Dog Foundation requires an annual stool sample even for dogs on heartworm and
tick prevention.
Date of most recent stool sample (must be within the last six months)_______
Result__________
Is the dog on heartworm preventative? ________________________
Is the dog on an appropriate tick prevention regime? _____________
| PO Box 1484 | New York, NY 10276 | (888) 859-9992 | Fax (888) 861-7312
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