Dog Number:      
Today’s Date        <<< please enter the date you filled out this form.

LIFETIME CARDIAC STUDY FOLLOW-UP FORM   -   Final Form

THANK YOU for participating in the lifetime cardiac study with (Dog’s call name) :      .
Please check the following for accuracy and change if needed.
Owner’s name:       Owner’s phone:       (please provide if willing)
Street Address:        City:       State:        Zip:      
Dog birth date:        Sex: ?   M    F     Registered name:      

We are winding down the Lifetime Cardiac study. This is the last form you will receive. Thanks for your participation in the study.

Did your dog develop heart disease since your last report to the study?   Y    N
Did your dog develop A-Fib since your last report to the study?   Y    N

If this dog is still living please check “Y” for the next question and return this form. 

Is your dog still alive?   Y   N.   If you checked “N” please answer the questions below and return this form.

Cause of death:      
Date of death:        Age at time of death:      
Was the dog euthanized?   Y    N. 
If an autopsy was done, please enclose a copy of the report or describe the results to the best of your ability: 
     

After completing the form, please save it as an RTF file (Rich Text Format, which is supported by most word processors under the Save As command) and email to whforms@aol.com or, if you prefer, print the form and snail mail it to The Irish Wolfhound Foundation, c/o Jane Harris, 1312 Professional Blvd Suite 200, Evansville, IN, 47714-8007.