Cardiac Exam Registration

Auscultation Only (Basic Cardiac Database): These forms can be filled out before the clinic.  Please go to ofa.org (https://www.ofa.org/application-forms ) to print and fill out the basic cardiac database form. 

Echocardiograms + Auscultations (Advanced Cardiac Database): Dr. Kellihan’s team will provide the required paperwork and the owner/breeder will fill out the paperwork the day of the clinic.

The following information is needed for all forms:

• Registered name
• Registration number
• Date of Birth
• Microchip number (if applicable)
• Sire registration number
• Dam registration number

Spots are limited! Register and pay for the Cardiac Clinic below.

Canine Cardiac Clinic Registration Form

Owner Name: *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Breed *

Dog's Registered Name *

AKC Number *

Sire's Registration Number: *

Dam's Registration Number: *

Microchip Number (enter NA if not microchipped): *

Tatoo Number (enter NA if not tattooed): *

I prefer:

• Saturday
• Sunday

Exam fees are non-refundable! Select your cardiac exam here:Echocardiogram - $ 275.00Ausculation Only - $ 55.00

Exam fees are non-refundable! By entering your credit card information below, you acknowledge that registrations are final and there are no refunds. Stripe Credit Card *

Card

Name on Card

Submit