UVTHS Canine Blood Donor Registration Form

Pets, cats and dogs, and their owners can give the gift of life to other animals thanks to our blood bank at the University Veterinary Teaching Hospital Sydney.

All donor animals undergo screening for eligibility, including health checks and complimentary blood tests.

Please register your details to submit your pet hero!
- Full Name
  
  PrefixFirst NameLast Name
- Mobile Number
  Format: 0000 000 000.
- Secondary Contact
  
  PrefixFirst NameLast Name
- Secondary Phone
  
  Area CodePhone Number
- E-mail
- Current Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Preferred method of contact
- What is your pets name?
- What is {petName}'s species?
- What is {petName}'s breed?
- What is {petName}'s age?
- How long have you owned {petName}?
- What is {petName}'s sex?
- Is {petName} desexed?
- Has {petName} ever had a litter of puppies/kittens?
- Is {petName} up to date with core vaccinations?
- Has {petName} received a vaccination for Leptospirosis (dogs only)?
- Is {petName} up to date with internal and external parasite control (flea/tick/worm/heartworm)?
- List all parasite control {petName} is on:
- Is {petName} currently on any medications?
- List all medications:
- List any health conditions/recent illnesses or surgery {petName} has had:
- Has {petName} ever received a blood transfusion?
- Has {petName} donated blood before?
- Has {petName} ever been outside of Australia?
- What country?
- I can confirm {petName} weighs more than 20kgs (dogs) or more than 4kgs (cats)
- Is the UVTHS Primary Care team your usual vet?
- Clinic Name
- Vet Name
- Were you
  
  Other
- Please attach any relevant documents
  
  Upload a File
  
  Cancelof
- By signing below or by authorizing treatment to the animal named above:
  - I declare that I am over 18 years of age;
  - I represent that I am the owner of the animal or that I am authorised by the owner to authorise treatment to the animal and accept this agreement on the owner’s behalf;
  - I agree to pay all outstanding fees due on completion of consultation or treatment or on discharge of the animal from hospital. Please note that we do not accept ‘Diners Club’ or personal cheques;
  - I understand and agree that all medical records and diagnostic images (e.g. radiographs) generated on my behalf by the University Veterinary Teaching Hospital Sydney (UVTHS) remain the property of UVTHS.;
  - I consent to allow any data, images or samples obtained as part of the examinations or treatments at UVTHS to be provided to my referring veterinarian(s) and to be retained and used by UVTHS and the Sydney School of Veterinary Science for educational and research purposes provided confidentiality is assured;
  - I consent for UVTHS staff to obtain my pets medical records from any other veterinarian or veterinary clinic if required; and
  - I have read and understood these terms and conditions and accept that they form a legally binding agreement with UVTHS.
- We may use photos of your pet on our social medial sites for promotional and marketing purposes.
- Privacy Statement
  We collect and use personal information in accordance with our Privacy Policy. We may share your personal information with other University of Sydney entities and with third parties that assist us with management and administration of our hospital including mailing, billing, delivery and technology services. More information about the handling of personal information and a copy of our Privacy Policy can be found here
- Signature
- Should be Empty: