Name of Clinic: ____________________________________ Email: ___________________________   Phone Number: ______________________ Town: ______________________   State: ______ Dog's Name: __________________   Owner's Name: __________________ Date of most recent rabies vaccination:   ______________                                                Valid until:   ______________ Date of most recent distemper complex:  ______________                                                 Valid until:  ______________ Stool has been tested by ____________________ on _____________                                               (Lab name or in house test) Stool is:   Hooks Whips Tapes Rounds Coccidia Giardia Negative ______ ______ ______ ______ ______ ______ Positive ______ ______ ______ ______ ______ ______ If positive, the dog was treated with ____________________ on dates ______________                                                                       ( Name of drug(s) )

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