Watermark Veterinary Forms

Forms

Select which form you wish to submit:

Boarding Form

Owner Name

First Last

Owner Phone

Pet Name

Pet Species

Pet Gender

Date of Drop-Off

Date of Pick-Up

DIET

Food

Feeding Frequency

Food Amount

Please let us know how much to feed your pet.

MEDICATIONS

Please list all medications to be given. Name of medication, dose and frequency must be provided. Add a new field for each medication.

Medications

Add a new field for each medication.

EMERGENCY CONTACT

Emergency Contact (if different than owner)

First Last

Emergency Phone (if different than owner)

TERMS & CONSENT

Signature(Required)

(Please type owner name as signature)

Date

Chilled Semen Shipment

STUD INFORMATION

Owner Name

First Last

Registered Name (Stud)

Call Name

Breed

Registry

Registry Number

BITCH INFORMATION

Owner Name

First Last

Registered Name (Bitch)

Call Name

Breed

Registry Number

Registry

SEMEN SHIPPING ADDRESS

Clinic Name

Veterinarian Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PAYMENT DETAILS

Name on Credit Card

First Last

Cardholder Email

Where payment receipt will get sent.

Credit Card Number

Credit Card Expiration

MM/YY

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Signature

Type credit card holder name to sign

Date

Frozen Semen Storage

OWNER

First Name Last Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Stud Dog Call Name

Breed

Stud Dog Registered Name

Stud Dog Registration Number

List Co-Owners if applicable:

Add additional lines for each Co-owner

RECORD OF DISPOSITION

If the Stud Dog has co-owners, ONE person must be designated as the Collection Owner. The Collection Owner will be responsible for releasing, shipment, transfer or destruction of said semen. By signing this release, you are authorizing Watermark Veterinary Hospital to act as your agent to release frozen semen from said Stud Dog. All approvals must be made either by email, verbal or written consent with Watermark Veterinary Hospital. Watermark Veterinary Hospital will confirm each shipment that has been authorized. This authorization will remain in effect until cancelled by the Collection Owner or Watermark Veterinary Hospital.

Collection Owner Information

First Name Last Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

LEGACY OPTIONS: RECORD OF DISPOSITION UPON DEATH

In the event something happens to the Collection Owner of the semen, what would you like to do with the remainder of the collection(s)? This is an important decision as your stud dog’s legacy will be determined by the action that you choose.

Please select below

Transfer semen to the person listed below

Release ownership of the semen to Watermark Veterinary Hospital to thaw for destruction and disposal

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

CONSENT & TERMS

Owner Signature

Type owner name to sign

Date

WVH Representative Signature

Date

PAYMENT INFORMATION

By filling and submitting this form, I authorize Watermark Veterinary Hospital to charge the credit card indicated for the associated charges. Storage fees are $12 a month billed out annually for up to 100 straws on 10 canes.

Cardholder Name

First Last

Phone

Credit Card Number

Credit Card Expiration

MM/YY

CVV #

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card Holder Signature

Type Credit Card Holder name to sign

Date

Frozen Semen Shipment

Semen Storage Confirmation(Required)

Yes, I have confirmed that my veterinarian DOES have a storage facility available for frozen semen to ship at my convenience.

Ship semen on this date

Signature of Shipper

Type name of Shipper to sign

Date

Semen Information

Owner Name

First Last

Stud Name

Call Name

Breed

Registration

Semen Storage Facility Shipping Address

Clinic Name

Veterinarian Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bitch Information

Please fill out the below details for the purpose of insemination. If this is only a Semen Ownership Transfer, proceed to the next section.

Owner Name

First Last

Bitch Name

Call Name

Breed

Registration

IMPORTANT - PLEASE READ

CONFIRMATION OF PROPER PAPERWORK. Please ensure you have completed the following forms: Semen Disposition Form (signed and sent by the owner of the semen) and the Frozen Semen Shipment Form before proceeding and submitting this form.

Payment Details

Name on Credit Card

First Last

Phone

Credit Card Number

Credit Card Expiration

MM/YY

CVV #

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Signature of Credit Card Holder

Type cardholder name to sign

Date

Frozen Semen Disposition

PLEASE VERIFY THE INFORMATION BELOW IS ACCURATE & COMPLETE TO THE BEST OF YOUR KNOWLEDGE

Owner Name

First Last

Stud Registered Name

Stud Call Name

Stud Breed

Stud Registration #

Stud DNA #

Are you releasing ALL inventory?

Yes

If No, how many Breedings are you releasing?

DISPOSITION INSTRUCTIONS

As the owner (or agent of the owner) of the above identified semen, I authorize Watermark Veterinary Hospital to:

SHIP said semen to the person below for purpose of insemination

TRANSFER ownership of said semen to the person listen below

FOR PURPOSE OF INSEMENATION - fill out the Bitch information

Owner First Name Owner Last Name

Bitch Registered Name

Bitch Call Name

Bitch Breed

Bitch Registration #

New Semen Owner's Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Signature of Owner

Sign by filling your name or initials.

Date

Semen Freeze Form & Packet

Freeze Appointment Information

Freeze appointments are scheduled Monday thru Friday at 8am and 10am. The collection, evaluation and freeze process takes approximately 4-6 hours. Plan to be at your scheduled appointment for 30-45 minutes. We will be in contact with you throughout the process. You will receive a phone call and an emailed report after the freeze is completed to go over the results and answer any follow-up questions. If you need to cancel or reschedule, we ask that you do so at least 24 hours prior to your appointment as we block out a significant amount of time for freeze appointments.

AKC recognized breeds must have an AKC DNA number in order to register the collection and freeze. If the stud dog does not have a DNA number, we will collect a sample the day of the freeze. There is an additional fee and form required for this, which we will have you complete on the day of the appointment.

Your stud dog MUST be current on their Rabies Vaccine. We will need proof of a current Rabies Vaccine prior to the collection.

We always recommend bringing a female in heat, if available, to the collection appointment. We do not guarantee that a female will be at our clinic at the time of your freeze. We do have scent available to use if needed.

A nose-to-tail exam will be completed on your stud dog on the day of the appointment as some disease processes, infections and inflammation can affect the quality of the semen. If we find that the semen is not of good quality, we will recommend further testing and treatment options. The freeze price will be converted and the cost of an exam, semen collection and evaluation.

The cost of the collection, evaluation and freeze is $550.00; storage fees are $12 a month billed out annually. Any additional freezes will be $400.00. If the freeze is converted to an exam and evaluation, the cost will be $205.00.

The following forms must be completed and submitted prior to the appointment.

STUD INFORMAITON

Stud Call Name

Stud Registered Name

Stud Registration Number

Stud Breed

OWNER INFORMATION

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Co-Owner(s) if Applicable

COLLECTION OWNER INFORMATION

If the Stud Dog has co-owners, ONE person must be designated as the Collection Owner. The Collection Owner will be responsible for releasing, shipment, transfer or destruction of said semen. By signing this release, you are authorizing Watermark Veterinary Hospital to act as your agent to release frozen semen from said Stud Dog. All approvals must be made either by email, verbal or written consent with Watermark Veterinary Hospital. Watermark Veterinary Hospital will confirm each shipment that has been authorized. This authorization will remain in ffect until cancelled by the Collection Owner or Watermark Veterinary Hospital.

Is the Collection Owner different than the Owner listed above?

Yes

Collection Owner Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

LEGACY OPTIONS: Record of Disposition upon Death

In the event that something happens to the collection owner of the semen, what would you like us to do with the remainder of the collection(s)? This is an important decision as your stud dog’s legacy will be determined by the action that you choose.

Legacy Option

Transfer Semen to the person listed below.

Release ownership of the semen to Watermark Veterinary Hospital to thaw for destruction/disposal.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

AGREEMENT & CONSENT

Watermark Veterinary Hospital Agreement

This is an agreement between Watermark Veterinary Hospital and the stud owner(s).

Watermark Veterinary Hospital DOES NOT warrant or guarantee in any way that insemination of this semen will result in a successful pregnancy or birth.

Watermark Veterinary Hospital SHALL NOT BE RESPONSIBLE for the loss or accidental thawing of semen, which results from tank failure, from an act by non-employees, natural disasters, fire or theft. The liability of Watermark Veterinary Hospital to the owner shall be limited to the storage fee paid for the current year.

Watermark Veterinary Hospital carries limited liability insurance to protect the cost of your semen in the event of the above noted circumstances. We HIGHLY RECOMMEND that you, as the owner, cover your semen with your own personal insurance. The fees and payment schedule for freezing semen and storage were outlined prior to this agreement and are due at the time of service. Fees are subject to change.

By signing below, the owner(s) agrees to the entire understanding of this document. All the provisions of this agreement shall be binding to both parties, the owner and Watermark Veterinary Hospital and any respective heirs, legal representatives and successors.

I authorize Watermark Veterinary Hospital to automatically charge the credit card indicated for $144.00 in January of each year for payment of my annual storage fee (up to 100 straws or 10 canes).

Signature

Sign by filling your name or initials

Date

CREDIT CARD AUTHORIZATION

By filling the below information, I authorize Watermark Veterinary Hospital to charge the credit card indicated for the associated charges. Storage fees are $12 a month billed out annually for up to 100 straws on 10 canes.

Name on Credit Card

First Last

Credit Card Number

Credit Card Expiration

MM/YY

CVV

Billing Details - If same as owner details above, you can leave blank.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Would you like to save your profile and associated credit cards on file at Watermark Veterinary Hospital?

Yes

Signature

Sign by filling your name or initials

Date

Watermark Veterinary Forms

Forms

New Client Form

PET INFORMATION:

Boarding Form

DIET

MEDICATIONS

EMERGENCY CONTACT

TERMS & CONSENT

Drop off form

REASON FOR TODAY'S VISIT

Chilled Semen Shipment

STUD INFORMATION

BITCH INFORMATION

SEMEN SHIPPING ADDRESS

PAYMENT DETAILS

Frozen Semen Storage

RECORD OF DISPOSITION

LEGACY OPTIONS: RECORD OF DISPOSITION UPON DEATH

CONSENT & TERMS

PAYMENT INFORMATION

Frozen Semen Shipment

Semen Information

Semen Storage Facility Shipping Address

Bitch Information

IMPORTANT - PLEASE READ

Payment Details

Frozen Semen Disposition

PLEASE VERIFY THE INFORMATION BELOW IS ACCURATE & COMPLETE TO THE BEST OF YOUR KNOWLEDGE

DISPOSITION INSTRUCTIONS

Semen Freeze Form & Packet

STUD INFORMAITON

OWNER INFORMATION

COLLECTION OWNER INFORMATION

LEGACY OPTIONS: Record of Disposition upon Death

AGREEMENT & CONSENT

CREDIT CARD AUTHORIZATION

Contact Info

Office Hours

Watermark Veterinary Hospital

Watermark Vet Forms Page

Watermark Veterinary Forms

Forms

New Client Form

PET INFORMATION:

Boarding Form

DIET

MEDICATIONS

EMERGENCY CONTACT

TERMS & CONSENT

Drop off form

REASON FOR TODAY'S VISIT

Chilled Semen Shipment

STUD INFORMATION

BITCH INFORMATION

SEMEN SHIPPING ADDRESS

PAYMENT DETAILS

Frozen Semen Storage

RECORD OF DISPOSITION

LEGACY OPTIONS: RECORD OF DISPOSITION UPON DEATH

CONSENT & TERMS

PAYMENT INFORMATION

Frozen Semen Shipment

Semen Information

Semen Storage Facility Shipping Address

Bitch Information

IMPORTANT - PLEASE READ

Payment Details

Frozen Semen Disposition

PLEASE VERIFY THE INFORMATION BELOW IS ACCURATE & COMPLETE TO THE BEST OF YOUR KNOWLEDGE

DISPOSITION INSTRUCTIONS

Semen Freeze Form & Packet

STUD INFORMAITON

OWNER INFORMATION

COLLECTION OWNER INFORMATION

LEGACY OPTIONS: Record of Disposition upon Death

AGREEMENT & CONSENT

CREDIT CARD AUTHORIZATION

Contact Info

Office Hours

Watermark Veterinary Hospital