Form 3 for Yorkie Encephalitis

Form 3 should be filled out by ALL Yorkie owners participating in encephalitis research. It asks for general information on the pet's health, vaccine history, family history and owner contact information.

Press the 'send' button when you are done. For correction before sending, press 'oops' If the form isn't working, please just e-mail Us the information.

(Please don't use a P.O. Box for addresses, we need an actual location)

Owner Information:
Your Name:

Your address: City:

State: Zip Code:

Home phone: Work phone:

Cell phone: Email:

May we contact you for additional information if necessary?
Yes No
If yes, what do you prefer?
E-mail Phone

Pet Information:
Registered Name: Call Name:
AKC Number: Date of Birth:
Sex: Status:(Spayed, Neutered, Unaltered)
Height: Weight:
Is pedigree available and included with form? Yes No
If no: Can you mail this to Dr. Barber
Will Mail Will not Mail

Date of last Vacination: Administered Vacinations:

Vet Contact Info:
City: State: Zip:

Please provide a brief medical history (including when signs / symptoms of encephalitis first began, what the signs / symptoms were, how the signs / symptoms have progressed over time, what medications have been administered, did the signs / symptoms improve or worsen with medication):

Please describe any other known medical conditions:
Current medications (name, dose, how often they are administered):

Additional Comments:

Press send only once!

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