PHR-English-Adult
|A. Owner’s Identification B. Dog’s Identification/Breeder’s Info |
|Owner’s Name (Last, First, MI) |Call Name |
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|Co-Owner’s Name (Last, First, MI) |Registered Name |
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|Owner’s Address |Permanent Identification (Microchip #) |
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|City |State |Zip |Country |Breed |
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|Co-Owner’s Address |Date of Birth |Date Purchased/Adopted |
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|City |State |Zip |Country |Color |Sex |
| | | | | |Male Female Neutered |
|Home Phone |Work Phone |Breed Registration Number |
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|Cell Phone |Email Address |Rabies Tag Number |
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|Additional Contacts for Urgent Care |Sire’s Registered Name |Sire’s Call Name |
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|Handler/Agent Name (Last, First) |Dam’s Registered Name |Dam’s Call Name |
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|Address |Breeder |
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|City, State |Zip |Breeder’s Kennel Name |
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|Home Phone |Work Phone |Breeder’s Address |
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|Cell Phone |Email Address |City |State |Zip Code |Country |
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|Breed Health Question Contact |Home Phone |Work Phone |
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|Email Address |Cell Phone |Email Address |
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|Phone Numbers |Co-Breeder’s Name |
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|Breed Health Question Contact |Address |
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|Phone/Email |Phone |Email |
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|C. Veterinarians/Pet Care Providers |
|Specialty Primary Care Emergency |Phone |Emergency Phone |
|Reproduction Rehab Holistic Medicine | | |
|Name |Email Address |
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|Group or Association |Fax |
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|Address |Web Address/URL |
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|City |State |Zip Code | |
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|Specialty Primary Care Emergency |Phone |Emergency Phone |
|Reproduction Rehab Holistic Medicine | | |
|Name |Email Address |
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|Group or Association |Fax |
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|Address |Web Address/URL |
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|City |State |Zip Code | |
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|Specialty Primary Care Emergency |Phone |Emergency Phone |
|Reproduction Rehab Holistic Medicine | | |
|Name |Email Address |
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|Group or Association |Fax |
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|Address |Web Address/URL |
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|City |State |Zip Code | |
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|Specialty Primary Care Emergency |Phone |Emergency Phone |
|Reproduction Rehab Holistic Medicine | | |
|Name |Email Address |
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|Group or Association |Fax |
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|Address |Web Address/URL |
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|City |State |Zip Code | |
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|D. Insurance |
|Insurance Provider Type |
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|Company Name |
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|Address |Agent |
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|City |State |Zip Code |Phone |
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|Plan Number |Fax |
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|E. Medical History(Check appropriate) |
|Condition |Date of Onset |Resolved |Date Resolved |
| |Lameness | | Yes | No | |
| |Rash | | Yes | No | |
| |Intestinal Parasites | | Yes | No | |
| |Cough | | Yes | No | |
| |Ear Infection | | Yes | No | |
| |Eye Infection | | Yes | No | |
| |Urinary Incontinence | | Yes | No | |
| |Urinary Tract Infection | | Yes | No | |
| |Diarrhea | | Yes | No | |
| |Constipation | | Yes | No | |
| |Poor Appetite | | Yes | No | |
| |Lethargy | | Yes | No | |
| |Bloat | | Yes | No | |
| |Spenic Torsion | | Yes | No | |
| |Seizures | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
| | | | Yes | No | |
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|F. Immunizations |
|Immunization for |Date |Date |Date |Date |Date |Date |
|Canine Parvovirus | | | | | | |
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|Canine Distemper Virus | | | | | | |
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|Canine Adenovirus | | | | | | |
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|Rabies | | | | | | |
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|Parainfluenza Virus | | | | | | |
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|Bordetella bronchiseptica | | | | | | |
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|Borrelia burgdorferi (Lyme Disease) | | | | | | |
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|Leptospira interrogans | | | | | | |
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|Porphyromonas sp (periodontal disease) | | | | | | |
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|G. Allergies/Drug Sensitivities |
|Allergy/Sensitivity Type (include medications| | | |
|foods environmental or other) |Reaction |Date last Occurred |Treatment |
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|H. Family/Pedigree Health Concerns |
| Epilepsy/Seizures |Description |Affected Relatives |
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| |Description |Affected Relatives |
|Cancer | | |
| Joint Diseases |Description |Affected Relatives |
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| Splenic Torsion |Description |Affected Relatives |
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| |Description |Affected Relatives |
|Bloat | | |
| |Description |Affected Relatives |
|Allergies | | |
| |Description |Affected Relatives |
|Hernia | | |
| |Description |Affected Relatives |
|Eye Problems | | |
| |Description |Affected Relatives |
|Other | | |
| |Description |Affected Relatives |
|Other | | |
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|I. Health Log (Major Illnesses) |
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|Date Diagnosed |Vet |Illness |Age at Onset |Status |Comments |
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|J. Medications |
|Note: Include all prescription medications, over-the-counter medications (taken on a regular basis), vitamin supplements, and herbal remedies |
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|K. Veterinarian Outpatient Visits |
|Date |Veterinarian |Reason |Remarks |
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|L. Hospitalizations/Surgeries |
|Hospitalization Type (Elective, Emergent, etc) |Diagnosis |
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|Admission Date |Discharge Date |Treatment |
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|Veterinarian |Outcome |
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|Hospitalization Type |Diagnosis |
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|Admission Date |Discharge Date |Treatment |
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|Veterinarian |Outcome |
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|Hospitalization Type |Diagnosis |
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|Admission Date |Discharge Date |Treatment |
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|Veterinarian |Outcome |
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|Hospitalization Type |Diagnosis |
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|Admission Date |Discharge Date |Treatment |
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|Veterinarian |Outcome |
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|Hospitalization Type |Diagnosis |
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|Admission Date |Discharge Date |Treatment |
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|Veterinarian |Outcome |
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|Hospitalization Type |Diagnosis |
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|AdmissionDate |Discharge Date |Treatment |
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|Veterinarian |Outcome |
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|Hospitalization Type |Diagnosis |
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|AdmissionDate |Discharge Date |Treatment |
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|Veterinarian |Outcome |
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|M. Lab Tests |
|Test Type |Date |Test Type |Date |
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|Requesting Vet |Administered by |Requesting Vet |Administered by |
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|Reason |Reason |
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|Result |Result |
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|Test Type |Date |Test Type |Date |
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|Requesting Vet |Administered by |Requesting Vet |Administered by |
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|Reason |Reason |
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|Result |Result |
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|Test Type |Date |Test Type |Date |
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|Requesting Vet |Administered by |Requesting Vet |Administered by |
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|Reason |Reason |
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|Result |Result |
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|N. Imaging (Examples: X-ray, MRI, Ultrasound) |
|Test Type |Date |Test Type |Date |
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|Requesting Vet |Administered by |Requesting Vet |Administered by |
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|Reason |Reason |
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|Result |Result |
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|Test Type |Date |Test Type |Date |
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|Requesting Vet |Administered by |Requesting Vet |Administered by |
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|Reason |Reason |
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|Result |Result |
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|O. Physical Therapy/Rehab |
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|Therapy Type |Start Date |Stop Date |Frequency |Therapist |
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|P. Dental Health |
|Date of Visit |Vet |Problems |Resolution |
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|Q. Health Clearances |
| Hips (OFA) |Reference Number |Date of Test |Vet |
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|Test Results |
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| Hips (PennHip) |Reference Number |Date of Test |Vet |
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|Test Results |
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| Shoulders |Reference Number |Date of Test |Vet |
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|Test Results |
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| Elbows |Reference Number |Date of Test |Vet |
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|Test Results |
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| Patella |Reference Number |Date of Test |Vet |
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|Test Results |
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| Cardiac |Reference Number |Date of Test |Vet |
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|Test Results |
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| Eye (CERF) |Reference Number |Date of Test |Vet |
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|Test Results |
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| Eye (CERF) |Reference Number |Date of Test |Vet |
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|Test Results |
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| Eye (CERF) |Reference Number |Date of Test |Vet |
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|Test Results |
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| Eye (CERF) |Reference Number |Date of Test |Vet |
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|Test Results |
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| Other |Reference Number |Date of Test |Vet |
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|Test Results |
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|R. Reproductive Health/Breeding - Bitches |
|Heat Cycle Start |Heat Cycle End |Hormone Testing |Comments |
| | |Day # |Result | |
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|Dates Bred & Method |Stud Dog Information |
| |Owner |Owner ‘s Phone |
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| |Dog’s Name |Owner’s Address |
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| |Stud Dog Registration # |Stud Dog DNA # |
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|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |
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|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |
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|Whelping Details |
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|Dates Bred & Method |Stud Dog Information |
| |Owner |Owner ‘s Phone |
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| |Dog’s Name |Owner’s Address |
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| |Stud Dog Registration # |Stud Dog DNA # |
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|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |
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|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |
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|Whelping Details |
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|Dates Bred & Method |Stud Dog Information |
| |Owner |Owner ‘s Phone |
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| |Dog’s Name |Owner’s Address |
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| |Stud Dog Registration # |Stud Dog DNA # |
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|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |
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|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |
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|Whelping Details |
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|S. Reproductive Health/Breeding - Dogs |
|Semen Evaluation Dates |Semen Evaluation Results |
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|Frozen Semen Storage/Use |
|Facility |Collection Date |Lot/Tracking # |Date Used |Brood Bitch |
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|Dates Bred & Method |Brood Bitch Information |
| |Owner |Owner ‘s Phone |
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| |Bitch’s Name |Owner’s Address |
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| |Bitch’s Registration # |Bitch’s DNA # |
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|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |
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|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |
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|Litter Details |
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|Dates Bred & Method |Brood Bitch Information |
| |Owner |Owner ‘s Phone |
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| |Bitch’s Name |Owner’s Address |
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| |Bitch’s Registration # |Bitch’s DNA # |
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|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |
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|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |
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|Litter Details |
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|Dates Bred & Method |Brood Bitch Information |
| |Owner |Owner ‘s Phone |
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| |Bitch’s Name |Owner’s Address |
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| |Bitch’s Registration # |Bitch’s DNA # |
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|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |
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|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |
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|Litter Details |
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|Dates Bred & Method |Brood Bitch Information |
| |Owner |Owner ‘s Phone |
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| |Bitch’s Name |Owner’s Address |
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| |Bitch’s Registration # |Bitch’s DNA # |
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|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |
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|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |
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|Litter Details |
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|Dates Bred & Method |Brood Bitch Information |
| |Owner |Owner ‘s Phone |
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| |Bitch’s Name |Owner’s Address |
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| |Bitch’s Registration # |Bitch’s DNA # |
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|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |
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|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |
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|Litter Details |
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