Belgian Sheepdog Club of America, Inc.
HEALTH REGISTRY QUESTIONNAIRE

IDENTIFICATION OF DOG
Registered Name:______________________________________________________
Male Female (Circle one)
Registration # (AKC or UKC, if known. Please provide copy of registration certificate if possible):____________________
Date of Birth:_______________
Date of Death, if applicable:_______________
Cause of death. Please submit copy of necropsy (autopsy) report if available:

___________________________________________________________________________

_______________________________________________________________

Please complete the following information on your dog's pedigree, or preferably provide a copy of a four generation pedigree:

______________________________________________
Grandsire
______________________________________________
Sire
______________________________________________
Granddam
______________________________________________
Grandsire
______________________________________________
Dam
______________________________________________
Granddam

IDENTIFICATION OF OWNER/BREEDER
Name of breeder:____________________________________________________________
Address:____________________________________________________
________________________________________
Phone :______________________________________________
Name of current owner:______________________________________________________
Address:________________________________________________
____________________________________________
Phone :______________________________________________
Your Name:________________________________________________________________

You are (circle all that apply): Breeder Former Owner Current Owner

RELEASE

I am the owner or breeder of the dog identified above. I have personal knowledge of the information I have provided and it is true and correct as of the date I have completed this survey. I understand that the Belgian Sheepdog Club of America intends to provide this information on request to club members who participate in the health registry and hereby permit the Club to do so. I waive any and all rights I may have against the Club in connection with its use of the information I have provided.

Signature: __________________________________________________________________________________________
Date:_______________________________________