Staff should explain to clients that in order to refer ...



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 Exempted Dogs?[i]|Yes No |

|Has your dog ever been aggressive towards other dogs? |Yes No If yes, please provide details |

| | |

|Has your dog ever been aggressive towards people? |Yes No If yes, please provide details |

| | |

| | |

|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?[ii] | |

5. Veterinary Care

|Is your dog registered with a vet?[iii] |Yes No If yes, please provide contact details |

| | |

| | |

| | |

| | |

|Does your dog have veterinary insurance? |Yes No |

|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-term illnesses? |Yes No If yes, please provide details |

|ie arthritis, ear infections or skin problems | |

| | |

| | |

|Is there someone who could take responsibility for your |Yes No If yes, please provide contact details |

|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

hopeproject@.uk

Notes

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[i] 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

[ii] Dogs Trust recommends that dogs are not left alone for longer than 4 hours each day

[iii] 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.

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