Blood Donor Questionnaire

CLIENT INFORMATION

PET INFORMATION

AUTHORIZATION TO TREAT

Initial Screening: I, the undersigned owner or the agent of the owner of the above-described
pet, give permission for the doctor(s) and staff of Wise Owl Animal Hospital to perform an initial exam of my pet and collect lab specimens for submission, to determine if my pet is a blood donor candidate.

I understand there is no fee incurred today should my pet pass the initial screening. I understand if there are abnormal findings that prevent my pet from becoming a blood donor, Wise Owl will pay half (50%) of the testing incurred and I will be responsible for the
remaining balance. I understand it is my responsibility to follow up, incur and pay for further diagnostics or treatment.

Blood Donation: I, the undersigned, certify I am the owner or authorized agent of the owner for the above-described pet. I authorize the doctors and staff of Wise Owl Animal Hospital to possibly sedate my pet should it be necessary and collect blood from my pet. I have been advised of the nature of the procedure and the potential risks. I understand that after the procedure and for the rest of the day, I can expect my pet to be groggy, tired, and possibly dysphoric. 

Blood Donor Benefits: The specific individual pet approved as a “participant” in the blood donor program shall receive the following benefits for the duration of the program:

• $50 credit upon completion of each donation
• 100% discount on ALL bloodwork on the donation (upon passing pre-screening)
• 20% off preventions
• 50% off DHLPP and Bordetella vaccines

Donor Program Agreement: I, the undersigned, agree to be a part of the blood donor program for 2 years. I understand that Wise Owl staff will contact me should they need my pet’s donation services. I understand that should I be contacted on three separate occasions for donation services and fail to bring in my pet due to declination or being unreachable I will be removed from the blood donor program. 

I also understand that I and any of my pets will be ineligible for the program in the future. Additionally, upon removal from the program due to my failure to comply with the above-mentioned terms, be immediately charged for any services provided to my pet at discounted prices related to the blood donor program. This billing will be due within 2 weeks and if unpaid for 31 days I will be sent to collections and credit reporting.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.