Medical and Veterinary Consent Form

1

Owner's Name* This field is required.Person/s relinquishing the Labrador

Prefix

First Name

Last Name

2

Second Owner's Name

Prefix

First Name

Last Name

3

Owner's current address* This field is required.

Street Address

Street Address Line 2

Town or City

County

Postal Code

Country

4

Owner's mobile phone number* This field is required.

5

Alternative phone number

6

Owner's email* This field is required.Please put n/a if there is no email address

example@example.com

7

Owner's previous address if applicable

Street Address

Street Address Line 2

Town or City

County

Postal Code

Country

8

Name of dog* This field is required.

9

Age of dog * This field is required.Please also include the Date of Birth if known

10

Microchip Number * This field is required.

This should be 15 digits

12

Please list details of any accidents, illnesses and / or current ailments the dog has or had.* This field is required.Please put n/a if the dog hasn't had any of the above

13

Name, address and contact details of the Veterinary Practice(s) which the dog is registered with* This field is required.If the dog hasn't been registered with any Veterinary Practice in its lifetime, please put n/a

14

Is the dog insured?* This field is required.

Yes

No

15

If yes, please note the insurance company and policy number.

16

1. I confirm that I am the owner of the dog named above and that it has been registered at the veterinary practice named above. OR I confirm that if the dog hasn't been registered at any veterinary practice, there are no known illnesses/existing medical conditions or ailments and no medical history* This field is required.

Yes, I confirm

17

2. I give permission for The Labrador Rescue Trust to contact the veterinary practice in order to obtain a full veterinary history for the dog(s) named if applicable and I give permission for the veterinary practice to provide The Labrador Rescue Trust with this information.* This field is required.

Yes, I give permission

18

3. I give permission for this information to be used by any vets employed by The Labrador Rescue Trust as needed during the time the dog is under the ownership and care of The Labrador Rescue Trust* This field is required.

Yes, I give permission

19

Owner's signature* This field is required.

Clear

20

I confirm that the Details of Dog for Rehoming form has also been completed* This field is required.https://form.jotform.com/LabradorRescueTrust/Details-of-Dog-For-Rehoming

Yes, I confirm that I have also completed and submitted the Details of Dog for Rehoming form