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BOXER ASSOCIATION OF VICTORIA
HEART SCREENING PROGRAM
NB:  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

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ANKC Reg. No: .......................................... Microchip No: .......................................

Date of Birth :/ / Sex : .............. Colour ..............................................

Owners Name : ..................................................................................................................................................

Address :..................................................................................................................................................

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SECTION B - ( to be completed by the Veterinarian ( Vet to strike out as applicable and initial ))

I have today, / / , examined the Boxer identified to me as above by Microchip number.

* 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.

Signed: .....................................................................

Name Address of Veterinarian......................................................................

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Forward completed form, AND self addressed stamped envelope to:
Lionel Bleakley, 840 Riddell Road, SUNBURY VIC 3429 Tel. 03 9740 8788

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OFFICE USE ONLY:

Heart Test No .

Certified by:


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