Health reporting form
Please use this form to report any health issues you have encountered in your HWV.

Please note the following:
• Please submit a seperate form for each condition.
• This form should only be completed by the owner or with the owner's explicit permission. You do not need to be a member of the HWVA to submit the form.
• This is seperate to previous health surveys and no information has been transferred from these. We would encourage you to submit the information again if possible.
• The purpose of this form is to collect data. We are happy to and plan to share the data we compile but neither the dog or owners name will form part of the information shared.
• We may ask if we can get back in touch with you in certain circumstances for example to gleen further information about an emerging condition. If you do not wish to be contacted any further about your response, that is perfectly OK, please just tick the corresponding box on the form.

Email address *
Your name *
Your answer
Your dogs name *
Please use your dogs pedigree name to allow us to differentiate respondants
Your answer
Your dogs sires name
Your answer
Your dogs dams name
Your answer
Your dogs date of birth
If you don't know this use an approximate date and tick the box below
MM
/
DD
/
YYYY
Is this date of birth an estimate?
Leave empty if not
Please tell us about the health condition you are reporting. *
Please tick what you consider the most relevent category and give further details in the space provided below this.
Required
Further information about the health problem
Your answer
We will assume you are happy for us to contact you about this report if necessary unless you tick the box below.
A copy of your responses will be emailed to the address you provided.
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