Sharon Myers Health Clearinghouse Form
Date:_____________ Dog's Age:___________ Gender:________ Symptoms:_____________________________________________________ Diagnosis:____________________________________________________ Treatment:____________________________________________________ Outcome:______________________________________________________ Additional Optional Information: Dog's Name:___________________________________________________ Your Name:____________________________________________________ Would you be willing to talk to other FCRSA members who experience a similar health problem with their dog(s)? _______
Send to:
Mary Jo Gallagher
5423 E 38th St N
Wichita KS 67220
Internet: mjgallag@dtc.net
Phone: 316-744-2860