Pre-Semen Collection for Assessment and Freezing Form

Please complete this form before your scheduled appointment. This is not a request for an appointment. To schedule an appointment or consult with a specialist, contact the main hospital line at (970) 297-5000.

Owner of Frozen Semen
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
- Select this box if you are NOT the owner of the stud, but WILL be the owner of the frozen semen
Stud Dog Details
Kennel Club Name*
Call Name*
Breed*
Color*
Date of Birth*
MM slash DD slash YYYY
AKC Registration*
Microchip Number*

A microchip number is required for export of all frozen canine semen
If imported, please list the country/countries of origin and date imported
Reproduction History
Has he been used as an active stud dog to sire litters before?*
- Yes
- No
If so, how many litters has he sired in his life?
Has he been collected for artificial insemination (AI) before?*
- Yes
- No
When was his last mating or AI?
MM slash DD slash YYYY
What proportion of his matings/AI’s resulted in pregnancy and production of pups?
What is his average litter size?
Any other comments on the history of your stud dog or history of the bitches used in these matings
General Health History
Has your dog been unwell or had any trauma in the past 12 months?
Is he on any medication? If so, please list the medication(s).
Has he had any noticeable abnormalities with his scrotum?
Any other comments regarding your dog’s health
Owner of Stud
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Export of Semen
In general, frozen semen is NOT eligible for export unless the conditions of the importing country are met prior to and at the time of collection. It is the client’s responsibility to advise CSU, prior to collection, if the semen is required for export. All dogs being collected for export MUST be microchipped in order to meet export requirements.
Is this semen intended for export?*
- Yes
- No
Which country?
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Contract Agreement*
I have read, understand and agree to the conditions.
The CLIENT accepts complete responsibility for any semen which may come into the charge of CSU, and in particular,
further accepts that any semen delivered to the Client or to any other person purporting to act as agent on behalf of the client from GlenBred rests with the client. The CLIENT acknowledges that payment for storage fees is due at the time of invoicing. IN THE EVENT that the client fails to pay amounts due and owing to CSU, the CLIENT acknowledges and agrees that CSU may choose to discard the semen without notice being given and without limitation to CSU’s right to recover the amounts due and owing from the CLIENT. All semen is stored and transported at the owner’s risk.

1. I understand that semen collected at CSU is not automatically eligible for export.
2. I verify that the dog identified above is the dog being presented for semen collection and freezing at CSU.
3. Semen storage price subject to change without prior notice
4. Insurance of semen in storage is the responsibility of the semen owner
5. I understand the limitation involved with exporting this frozen semen if I chose not to microchip the donor dog
Name
This field is for validation purposes and should be left unchanged.

Pre-Semen Collection for Assessment and Freezing Form

Owner of Frozen Semen

Stud Dog Details

Reproduction History

General Health History

Owner of Stud

Export of Semen

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