Online 2010 Veterinarian Form

ANNUAL HEALTH RECORDS REQUIRED FOR REGISTRATION AND RENEWAL

Name of Owner	Name of Dog	Breed	OTD# (For renewal only; # is on your ID card)

DATE PERFORMED MUST BE PROVIDED FOR EACH PROCEDURE

If the dog cannot be vaccinated, there has to be a proven clinical condition, for example, if the dog's immune system is compromised or has another illness which would be contraindicated should the dog be vaccinated. A signed clinical diagnosis from a Veterinarian must be submitted with this form. In the case of titers, a letter from your veterinarian explaining the reason for their use is required. A Vet's statement that, "In my professional opinion the dog should not be vaccinated." will not be sufficient. We cannot register a dog without a current Rabies vaccination.

MANDATORY ANNUAL CHECK-UP, DATE COMPLETED:

VACCINATIONS	Date Shot Given:	Expires
Rabies
Distemper
Hepatitis
Parvovirus
Lepto, Parainfluenza, Bordetella are at the discretion of the Vet. If not performed, please check here:
Leptospirosis
Bordetella/Para-influenza

REQUIRED ANNUAL PROCEDURES	P	N	Date
Fecal
A fecal test is mandatory even if the dog is on HW medication.
Heartworm
If Heartworm is not present in the geographic area where the dog resides then a HW test or preventative is at the discretion of the Veterinarian.

Type of HW medication(s)

Comments

Clinic Name:

Address:

City: Province: Postal Code:

Phone: Fax: Email:

I hereby certify that I have examined the above dog and to the best of my knowledge find the animal physically and mentally healthy.

Name of Licensed Veterinarian

Thank you from...

Ottawa Therapy Dogs
Suite 750
1500 Bank Street
Ottawa, ON K1H 1B8

613.261.6834
admin@ottawatherapydogs.ca