Your name                           

Your email address                

Your vizsla's registered name  

Your vizsla's date of birth       

Dog or bitch                         Dog Bitch

Spayed/Neutered                  Yes   No      If so at what age

Has your vizsla suffered from (tick all that apply)

   Polymyositis

   MMM (Masticatory Muscle Myositis)

   Myasthenia Gravis

   IBD (Inflammatory Bowel Disease)

   Polyarthritis

   IMHA (Immune Mediated Hemolytic Anemia)

   IMTP (Immune Mediated Thrombocytopenia)

   Addison's Disease

   Pemphigus

   Lupus (SLE or Discoid)

   Hypothyroidism (Thyroiditis)

   SLO (Symmetrical Lupoid Onychodystrophy) 

    SRMA (Steroid Responsive Meningitis-Arteritis)

   GI (Gastrointestinal) problems

   Allergies/Intolerance (food or skin)

 

Any other immune mediated illness? If so what

Age of onset of first illness             

Routinely vaccinated?              Yes   No

Routinely wormed eg frontline?  Yes  No

Please use this box to tell us more eg any "triggers" that you suspect

or alternatively email us with as much information as possible

 

Before submitting this form please type the security code numbers   1234    into the text box below