Microchip Registration Form

Please only complete and submit this form once you have your dog and their Pet Passport.

This form is only for adopters who live in the UK.

If you have any questions regarding this form, please email SavingSoulsAnimalRescue@gmail.com

Please put as many contact numbers and details as possible. Should we need them it will be easier to contact you. It is also vital that there are as many contact detail as possible in case your dog gets parted from you for any reason. Please keep your details up to date with the microchip company once you have the log in details, for example if you ever change telephone numbers or move house you must update these details, this is your responsibility once the dog is in your name.

Rescue Association:

Please enter other rescue organisation if different to Saving Souls Animal Rescue

Dog's Original Name: *

Dog's New Name (if different):

Dog's Date of Birth: *

Date of Birth is found on page 5 (number 5) of your Pet's Passport

Dog's Microchip Number: *

Microchip number is found on page 6 (number 2) of your Pet's passport and is 15 digits long

Dog's Microchip Implant Date: *

Microchip implant date is found on page 6 of your Pet's passport, date of application or reading

Dog's Pet Passport Number: *

Dog's Breed Description: *

Dog's Colour: *

Is your Dog Neutered/Spayed?: *

• YES
• NO

Dog's Gender: *

• Male
• Female

Any Conditions:

Any conditions, for example if your dog has 3 legs, is blind or they have Leishmania, please state the condition(s)

NEW KEEPER'S DETAILS - Full Name: *

First

Last

Title *

Home Tel:

Mobile Tel: *

Alternative Tel:

Email: *

Address: *

Post Code: *

Information - please complete checklist:

• The Cost of Microchip Registration is £20
• Please send payment via PayPal (preferred option) or bank transfer to our UK bank account (please use the last 4 digits of your dog's microchip number and their original name as reference). Payment details will be provided on receipt of this form submission
• Your dog's microchip details will not be updated until payment has been received

How will you make payment? *

• PayPal
• Bank Transfer

Today's Date *

Adopter Microchip Registration Privacy Policy *

• This is a Digital Signature and I give consent to the information on this form to be stored and processed by Saving Souls Animal Rescue for the purpose of microchip registration

Saving Souls Animal Rescue take your privacy seriously and we will only use your personal data on this form in connection with your microchip registration. We will never pass your information to any third party not connected to the process, and the details will not be used for marketing purposes of any third party. Your microchip registration form will only be held securely both electronically and/or on hard copy. Further information on our data protection and privacy is contained in our Data Protection Policy and our Privacy and Cookies Policy.

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