Submit Case History Online

Please use the form below to submit information about your dog’s case history. If you prefer to download the PDF version instead, please click here.

I hope to have a survey posted here on the site soon to gather basic information, but it would be most helpful in our data collection effort to have the completed form, and more importantly any veterinary records and other supporting information, that you are willing to share.

Dog's Details

Dog's Registered Name*

Call Name*

Titles

Date of Birth*

Registration Number

Owner

Owner(s) Name(s)*

Phone Number

Email Address*

Geography

Usual training location(s), what part(s) of the country visited for hunting and/or trialing*

Are you aware of the dog having been exposed to dangerous plants, such as foxtail, barley, cheatgrass, and/or Canada or Virginia wild rye grass? Where? How frequently?*

Manifestation of Illness

How did the illness manifest itself?
 Pyothorax Abscess Other

If abscess, please say where.

Case Notes Upload (doc, docx, pdf, odt, txt)

Where Treated (Facility)*

Date of Treatment(s)*

Describe procedure (and/or provide case notes where possible)*

Bacteria Identified*

Means of Identification (Pathology, Identification of Recovered Plant Material)*

Antibiotic(s) Given, Duration*

Treatment Outcome*

Seed(s) Recovered from [Area of Body, etc.]*

captcha
Enter the characters you see:

Comments are closed.