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Derbyshire - Scarsdale Vets Alfreton

Derbyshire - Scarsdale Vets Alfreton

Venue: Scarsdale Vets Alfreton
Unit 2,
Nottingham Road,
Alfreton,
Derbyshire
DE55 7GR

Contact: 01773 304900

Canine blood donation sessions take place across the year at Scarsdale Vets Alfreton. If your dog meets the donation criteria and you live near this practice, please register for a session.

Donor registration

Owner's details

Email address *

Title *

First name *

Surname *

Telephone number *

Mobile

Address line 1 *

Address line 2

City/town *

County/region

Postcode *

If you know the location of the donation session you would like to attend, please let us know

How did you hear about us?

please specify

Your privacy is important to us – please read our Privacy Policy

We would like to contact you to discuss your pet becoming a blood donor and need your permission to do so. Please can you confirm you are happy for one of our team to get in touch with you? *

Yes, I am happy for Pet Blood Bank to contact me
No, I do not want Pet Blood Bank to contact me

If you have selected no and would like your pet to become a donor, please give us a call at your convenience on 01509 232222 between the hours of 9am - 5pm Monday - Friday.

I consent to Pet Blood Bank UK contacting my vets for vaccine details, last known weight and clinical history should it be necessary for my registration to be processed

Yes
No

We may be unable to process your registration without this information. Please contact your vet and ask them to share your dog’s health and vaccination history with us.

Would you like to sign up for our e-newsletter?

Yes
No

How many dogs would you like to register? *

Dog's details

Dog's name *

Breed *

Sex of dog

Over 25kg (55Lbs)? *

Yes
No

Sorry, dogs must be over 25kg to donate

Aged between one and eight years? *

Yes
No

Sorry, dogs must be between one and eight years old to donate

Age? *

Date of last vaccination (month and year)? *

Fit and well? *

Yes
No

If no, please provide further details

History of heart murmur/seizures? *

Yes
No

Sorry, your dog is unable to donate

Taking any prescribed medication, including steroid ear drops or nasal sprays? *

Yes
No

If yes, please provide further details

Imported or travelled out with the UK and Ireland? *

Yes
No

Sorry, dogs that are imported or that have travelled out with the UK and Ireland are unable to donate

Received a blood transfusion? *

Yes
No

Sorry, dogs that have received a blood transfusion are unable to donate

Good temperament? *

Yes
No

If no, please provide further details about the dog's temperament

Neutered? *

Yes
No

Microchipped? If not, we will chip them free of charge *

Yes
No

Second dog's details

Dog's name *

Breed *

Sex of dog

Over 25kg (55Lbs)? *

Yes
No

Sorry, dogs must be over 25kg to donate

Aged between one and eight years? *

Yes
No

Sorry, dogs must be between one and eight years old to donate

Age? *

Date of last vaccination (month and year)? *

Fit and well? *

Yes
No

If no, please provide further details

History of heart murmur/seizures? *

Yes
No

Sorry, your dog is unable to donate

Taking any prescribed medication, including steroid ear drops or nasal sprays? *

Yes
No

If yes, please provide further details

Imported or travelled out with the UK and Ireland? *

Yes
No

Sorry, dogs that are imported or that have travelled out with the UK and Ireland are unable to donate

Received a blood transfusion? *

Yes
No

Sorry, dogs that have received a blood transfusion are unable to donate

Good temperament? *

Yes
No

If no, please provide further details about the dog's temperament

Neutered? *

Yes
No

Microchipped? If not, we will chip them free of charge *

Yes
No

Third dog's details

Dog's name *

Breed *

Sex of dog

Over 25kg (55Lbs)? *

Yes
No

Sorry, dogs must be over 25kg to donate

Aged between one and eight years? *

Yes
No

Sorry, dogs must be between one and eight years old to donate

Age? *

Date of last vaccination (month and year)? *

Fit and well? *

Yes
No

If no, please provide further details

History of heart murmur/seizures? *

Yes
No

Sorry, your dog is unable to donate

Taking any prescribed medication, including steroid ear drops or nasal sprays? *

Yes
No

If yes, please provide further details

Imported or travelled out with the UK and Ireland? *

Yes
No

Sorry, dogs that are imported or that have travelled out with the UK and Ireland are unable to donate

Received a blood transfusion? *

Yes
No

Sorry, dogs that have received a blood transfusion are unable to donate

Good temperament? *

Yes
No

If no, please provide further details about the dog's temperament

Neutered? *

Yes
No

Microchipped? If not, we will chip them free of charge *

Yes
No

Forth dog's details

Dog's name *

Breed *

Sex of dog

Over 25kg (55Lbs)? *

Yes
No

Sorry, dogs must be over 25kg to donate

Aged between one and eight years? *

Yes
No

Sorry, dogs must be between one and eight years old to donate

Age? *

Date of last vaccination (month and year)? *

Fit and well? *

Yes
No

If no, please provide further details

History of heart murmur/seizures? *

Yes
No

Sorry, your dog is unable to donate

Taking any prescribed medication, including steroid ear drops or nasal sprays? *

Yes
No

If yes, please provide further details

Imported or travelled out with the UK and Ireland? *

Yes
No

Sorry, dogs that are imported or that have travelled out with the UK and Ireland are unable to donate

Received a blood transfusion? *

Yes
No

Sorry, dogs that have received a blood transfusion are unable to donate

Good temperament? *

Yes
No

If no, please provide further details about the dog's temperament

Neutered? *

Yes
No

Microchipped? If not, we will chip them free of charge *

Yes
No

Fifth dog's details

Dog's name *

Breed *

Sex of dog

Over 25kg (55Lbs)? *

Yes
No

Sorry, dogs must be over 25kg to donate

Aged between one and eight years? *

Yes
No

Sorry, dogs must be between one and eight years old to donate

Age? *

Date of last vaccination (month and year)? *

Fit and well? *

Yes
No

If no, please provide further details

History of heart murmur/seizures? *

Yes
No

Sorry, your dog is unable to donate

Taking any prescribed medication, including steroid ear drops or nasal sprays? *

Yes
No

If yes, please provide further details

Imported or travelled out with the UK and Ireland? *

Yes
No

Sorry, dogs that are imported or that have travelled out with the UK and Ireland are unable to donate

Received a blood transfusion? *

Yes
No

Sorry, dogs that have received a blood transfusion are unable to donate

Good temperament? *

Yes
No

If no, please provide further details about the dog's temperament

Neutered? *

Yes
No

Microchipped? If not, we will chip them free of charge *

Yes
No

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Pet Blood Bank UK

Unit 21 & 22
, Loughborough Technology Centre
, Epinal Way
, Loughborough
, Leicestershire
, LE11 3GE
Call: 01509 232 222

01509 232 222

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