Veterinary Follow-Up

Assistance Canine Training Services
PO Box 52
North Conway, NH 03860
(603)383-2073
info@assistancecanine.org

A.C.T.S. has placed a Service Dog or Facility Dog with one of your clients. As part of their agreed upon follow-up procedure, we are asking you to fill out this short form. Keeping track of our placed dogs and their care is a large part of our follow-up and we appreciate your taking the time to keep us informed of the dog’s care and upkeep. Thank you!

Date

YYYY

Client

Client Name

First Name

Last Name

Dog Name

Veterinarian

Veterinarian Name

First Name

Last Name

Veterinary Hospital Name

Veterinary Hospital Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Veterinarian Phone

(###)

###

####

Medical Information

Most Recent Weight of the Dog (lbs)

Do you feel the dog is under or over weight?

Is the dog up to date on vaccination and/or titers?

To the best of your knowledge, is this dog being treated with heartworm prevention and monthly flea and tick prevention?

What vaccine does this dog receive?

Has this dog had any chronic medical issues over the past year?

Has this dog experienced any medical issues over the past year that may have been genetically passed to him/her?

Has this dog been involved in any accidents or had any illnesses that may indicate neglect?

Does this dog appear generally well groomed, brushed, bathed, and generally well cared for?

Do you have any additional comments or concerns?

I acknowledge that by entering my name below and submitting this application, that all the above information is accurate.

Name

First Name

Last Name

When you click the SUBMIT button, the final version of this form will be sent to A.C.T.S.

Veterinary Follow-Up

ACTS - Assistance Canine Training Services

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