ADDITIONAL LEVEL HEALTH CERTIFICATE APPLICATION

ADDITIONAL INFORMATION

For Silver or Gold or to aquire Gold stars
I'm applying for *
What Colour is this dog?*
You have ticked a Characterisitic which is Undesirable and will fail Silver level.

PLEASE DO NOT CONTINUE WITH THIS FORM
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
DOG'S NAME*
This will appear on the certificate exactly as you have written it
KENNEL CLUB NUMBER*
This will appear on the certificate exactly as you have written it
MICROCHIP NUMBER*
This will appear on the certificate exactly as you have written it

APPLY FOR GOLD CERTIFICATE

You need to complete each question or the form will not submit. Ensure you have received your Silver Certificate before continuing
PLEASE CONFIRM DOG'S DATE OF BIRTH*

DayMonthYear
Date
BRONZE CERTIFICATE NUMBER*
SILVER CERTIFICATE NUMBER (Leave blank if you are applying for Silver)
Tick if you have paid for posted Certificates also

YESNO
BVA or ECVO eye Scheme. Clear results on eye examination recorded. Test to be done at 2 years of age or over.*
UPLOAD PHOTO OF DOCUMENT*

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Heart screening by qualified Auscultation approved Veterinary Surgeon. (Grade 0)*
UPLOAD PHOTO OF DOCUMENT*

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RFGS (BOAS) (Grade 0,1)*
UPLOAD PHOTO OF DOCUMENT*

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APPLY FOR GOLD STARS
BRONZE CERTIFICATE No:*
SILVER CERTIFICATE No:*
GOLD CERTIFICATE No:*
Gold stars will be awarded for:

Spinal X-Ray (Thorax area).
Heart Doppler examination

HUU Clear

Kennel Club Stud Book Number

UK Champion

RFGS tested in the chamber at Cambridge University (Grade 0,1)

Please upload a clear photo your document(s) and we will send you your Stars. If the documents are blurry or unclear we may request clearer copies.
SPINAL XRAY

YES
UPLOAD DOCUMENT

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HEART DOPPLER

YES
UPLOAD DOCUMENT

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HUU CLEAR

YES
UPLOAD DOCUMENT

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STUD BOOK NUMBER

YES
UPLOAD DOCUMENT

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UK CHAMPION

YES
UPLOAD DOCUMENT

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RFGS - Tested in the chamber at Cambridge University and either Grade 0 or 1

YES
UPLOAD DOCUMENT

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ADDITIONAL INFORMATION