Blood Donor Agreement

Owner Information
First Name*
Last Name*
Address*
City/Town*
State*
Zip Code*
Email*
Preferred Phone*
Blood Donor Information
At Which Hospital Will Your Pet Donate Blood?*
- Premier - Grayslake
- Premier - Chicago
Species*
Pet's Name*
Sex of Donor*
Donor's Date of Birth, or Age (in years)*
Breed
Primary Care Veterinarian/Veterinary Clinic Name*
Medical & Lifestyle Information
Has he or she ever been used for breeding?*
- Yes
- No
- I Don't Know
Has she ever been pregnant?*
- Yes
- No
- I Don't Know
Has she ever given birth to a litter?*
- Yes
- No
- I Don't Know
Is he or she an indoor-only cat?*
- Yes
- No
Is he or she up to date on vaccinations?*
- Yes
- No
Do you give heart worm preventative?*
- Yes
- No
Does he or she have any current medical issues?*
- Yes
- No
Please list his or her medical issues
Is he or she on any medications?*
- Yes
- No
List
Medication Name Dose/Strength Reason
Has he or she ever received a blood transfusion?*
- Yes
- No
Name
This field is for validation purposes and should be left unchanged.

Δ

847-548-5300 | 1810 E. Belvidere Rd. Grayslake, IL 60030

PHONE: 847-548-5300

Our Services
For Your Pet
For Veterinary Teams
About Us
Blogs & Videos
- Our Blogs
- PAWEDcasts
Careers + Development

Website Design by Jackrabbit

Emergency Veterinary Care

June - September 2023 Hospital Hours

We are open during the following periods

Friday: open 7 a.m. onwards

Saturday: open 24 hours

Sunday: open 24 hours

Monday: open 24 hours

Tuesday: Open until Midnight

Wednesday: 7 a.m. – Midnight

Thursday: 7 a.m. – Midnight

July 4th: Open 24 hours

Prior to closing on weeknights, patients requiring overnight hospitalization will need to be transferred to an Ethos hospital in Somers, WI, or Chicago, IL. Please call to discuss this with a staff member.

Please call before you come in to ensure we are the best resource for your pet’s needs.

Phone: 847-548-5300

Nearby ER Hospitals

Medication Name	Dose/Strength	Reason

Blood Donor Agreement

Owner Information

Blood Donor Information

Medical & Lifestyle Information

Emergency Veterinary Care

June - September 2023 Hospital Hours

We are open during the following periods

Please call before you come in to ensure we are the best resource for your pet’s needs.