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      Thank you for taking the time to fill out this questionnaire. Once you have clicked the "Send" button you will be returned to this page and your submission will be at the head of the list. If may be necessary to hit the "refresh or reload" button if your form should fail to appear.

Fill in all fields below and then press the SEND button

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Your Name
E-mail Address
Enter a "complete" email address
(eg: yournameis@yourprovider.com)
City/State
Country
How did you get here?

Dog's Name
Breed of Dog or Mixed Breed
Dog's date of birth
Is the Dog Still Living
Dog's date of death (if applicable)
Sire
Dam
Type of food fed & frequency
For example:
dry, canned, raw, homemade or a combination
Was/Is your dog
vaccinated?
Remarks here would include:
At what age the first shot was administered and how frequent thereafter. The vaccine name(s). Ex: Distemper/Hepatitis/Lepto/Bordatella/Parvo/Parainfluenza/Lime
Health problems
(during his/her lifetime)
Cause of death if applicable
Breeder notified of
cause of death?
YES NO
Remarks
(anything that may be of help)

*


If your purebred dog has passed away, is currently fighting PF's or is in remission from this disease, it would be very helpful if you would e-mail the pedigree of your PF dog to Web Mistress Carol Kufner.This information will be used to compile an online data base for all members to access.