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Name of Primary Contact for Donor*
Primary Contact Number*
Secondary Contact Number
Date of Birth*
Origin/ Travel History Outside of NJ (list states/countries)*
*My pet has never been aggressive towards a person or other animals. (Blood donors should have a relaxed temperament and able to handle gentle restraint)
*My pet is current on their yearly physical exam and vaccinations recommended by my veterinarian and I can provide documentation.
*My pet is not on any medications except for flea/tick preventive and heartworm preventive. If any other medications please specify:
*My pet has never received a blood transfusion
*My pet has never been diagnosed or treated for a bleeding disorder, diabetes, Cushing's disease, liver disease, kidney disease, heart disease, seizures, or epilepsy.
*My pet (if an intact male or female) is not part of an active breeding program.
*DOGS ONLY: My dog is on heartworm preventive year round and flea/tick preventive seasonally.
NorthStar VETS understands that there may be circumstances when a donor can no longer be in the program for health or other reasons. Screening and maintaining a donor is of considerable cost to our program. We ask that if you do not think you can commit to bringing your pet in 4-8 times per year to give blood that you do not volunteer for this program.
Signature of Owner:*
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