Dog Referral Form
These questions are intended only as a guide. The information provided will help hostel staff to understand the dog and its needs and temperament before the owner moves into the hostel. Please use discretion and understanding when asking these questions.
1. Referral Agency Referral Agency: Contact Name: Contact Tel Number:
2. Owner Details Owner Name: Contact Tel Number:
3. Dog Details Dog Name: Dog Breed: Dog Sex: Male Female Dog Age: Dog Colour: Size: Small Medium Large Is your dog neutered? Yes No If female, could your dog be pregnant? Yes No Has your dog been microchipped? Yes No If yes, what is the microchip number?
4. Dog Temperament & Behaviour How long have you had your dog?
Where have you previously lived with your dog?
Is your dog registered on the Index of Yes No Exempted Dogs?1 Has your dog ever been aggressive Yes No If yes, please provide details towards other dogs?
Has your dog ever been aggressive Yes No If yes, please provide details towards people?
Does your dog need to wear a muzzle? Yes No Is your dog destructive when left alone? Yes No How long would you leave your dog alone during the day?2
5. Veterinary Care Is your dog registered with a vet?3 Yes No If yes, please provide contact details
Does your dog have veterinary Yes No insurance? When was your dog last vaccinated?
When was your dog last treated for worms? When was your dog last treated for fleas? Is your dog toilet-trained? Yes No Does your dog suffer from any long- Yes No If yes, please provide details term illnesses? ie arthritis, ear infections or skin problems
Is there someone who could take Yes No If yes, please provide contact details responsibility for your dog in case of an emergency?
For further information or advice, please contact:
Dogs Trust Hope Project 17 Wakley Street London EC1V 7RQ 020 7837 0006 [email protected]
Notes 1 Dogs registered on the Index of Exempted Dogs have been seized under the Dangerous Dogs Act 1991 and released onto the Index after being assessed as posing no danger to the public. For further advice please contact the Dogs Trust Hope Project 2 Dogs Trust recommends that dogs are not left alone for longer than 4 hours each day 3 All dogs living in a hostel should be regularly treated for fleas & worms and vaccinated annually. Dog owners living in a hostel are eligible to join the Dogs Trust Hope Project Veterinary Scheme, which provides these treatments free of charge.