Condition or circumstance ( please describe occurrence: time of day, symptoms, length of occurrence, medications given and results. Example - bloat, 10pm, not eating, hunched over, stomach hard, taken to vet and tubed - brought home and seems fine.)

Date of Death

I have previously completed a Health Incident report for this Collie (yes or no and date submitted)

Age of Collie

Is your Collie a:

Dog (male)
Bitch (female)

Is your Collie:

Intact
Spayed
Neutered

Permanent Identification:

None
Microchip
Tattoo

What variety is your Collie

Rough
Smooth

What color is your Collie:

Sable and White
Tri Color
Blue Merle
White
Sable Merle
Other (please explain in Other Comments section)

In what state or part of the country does your Collie live?

What brand and variety of dog food do you use?

What flea control product do you use:

What heartworm product do you use:

Which vaccinations has your Collie had:

Rabies
Parvovirus
Leptospirosis
Adenovirus
Distemper
Bordatella
Other (Please explain in Other Comments section)

Is this Collie competing in:

Conformation
Agility
Herding
Obedience
Other (Please explain in Other Comments section)

Breeding History:

If male, has this Collie been used at stud?
If male, will this Collie be used at stud in the future?
If female, has this Collie been bred?
If female, will this Collie be bred in the future?

What supplements and/or vitamin has this Collie received:

What products were used with this Collie before or that the time of onset of this incident

Other comments:

I am willing to be contacted privately by the Foundation to provide futher information. My email address or contact information is: