BOXER HEART SCREENING PROGRAMNB: The content or format of this form is NOT to be altered in any way or it will not be accepted!SECTION A - ( to be completed by the owner ) * DOGS VICTORIA REGISTERED NAME OF BOXER
Reg. No .............................. Date of Birth / / Sex .............. Colour ....................... Name & Address of Owner.................................................................................................................................................. .................................................................................................................................................. ------------------------------------------------------------------------------------------------- SECTION B - ( to be completed by the Veterinarian ) I have today, / / , examined the Boxer identified to me as above and represented on the endorsed photograph attached. * I could not detect any evidence of a heart murmur in this Boxer on the day. * I have referred the Boxer for examination by a cardiologist veterinarian. * I detected a heart murmur of grade /6 intensity. * Further investigation into the cause of the murmur by means of Doppler Echcardiography is strongly recommended.* This Boxer is under 1 year of age and should be re-checked when over 1 year old. ( Vet to strike out as applicable and initial ) Name Address of Veterinarian ...................................................................... (NB: attach photograph with the Boxer's name clearly printed on the reverse) Forward completed form,
endorsed photograph AND self addressed stamped envelope to: Heart Test No ……………. Certified by:……………………… |