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PET PARADE ENTRY FORM
Name____________________________________
Phone Number_______________
Parent / Guardian Name____________________________________________________
Address_________________________________________________________________
Entry
Class________________________________
Type of Pet________________
VETERINARIAN'S VERIFICATION OF VETERINARIAN-CLIENT-PATIENT
RELATIONSHIP
I, the undersigned, hereby verify the following:
1. I am a licensed practitioner of veterinary medicine.
2. I have established an ongoing
"veterinarian-client-patient relationship" with respect to certain
animals owned by
_________________________________________.
3. These animals are described and identified as
follows - all animals except for llamas, poultry, and rabbits - you may attach a
copy of the "Certificate of Veterinary Inspection" (CVI) to meet this
animal relationship requirement. Llamas, poultry, and rabbits do not need
a CVI but need to be identified on this form. Use additional sheets as
necessary.
Registration Name or Description_______________________________________________________________
4. I understand
this ongoing "veterinarian-client-patient relationship" to be a
relationship in which I, as a veterinarian have assumed the responsibility of
making veterinary medical judgments regarding the health of the animals
described in the preceding paragraph and the need for veterinary medical
treatment of those animals, and in which the animal owner or caretaker has
agreed to follow my instructions in relation to zoonotic diseases.
I verify the foregoing to be accurate. I make the foregoing statement
subject to the penalties of 18 Pa.C.S.A. 4904 (relating to un sworn falsification
to authorities). In witness of this, I have signed and dated this
verification below.
Signature of
Veterinarian____________________________________________
Date_______________________
Printed Name of
Veterinarian_______________________________________________________________________
Address of
Veterinarian__________________________________________________________________________
ANIMAL OWNER or CARETAKER'S VERIFICATION OF
VETERINARIAN-CLIENT-PATIENT RELATIONSHIP
I, the undersigned, hereby verify the following:
1. I am the owner / caretaker (circle either or both,
as applicable) of the animal(s) identified as follows by ear tag, tattoo, leg
band, etc. - all animals except for llamas, poultry, and rabbits - you may
attach a copy of the "Certificate of Veterinary Inspection" (CVI) to
meet this animal relationship requirement. Llamas, poultry, and rabbits do
not need a CVI, but need to be identified on this form. Use additional sheets
as necessary.
Registration Name or
Description_________________________________________________________________
2. I have established an ongoing
"veterinarian-client-patient relationship" for the animal(s) described
in the preceding
paragraph with ___________________________________(print name), a licensed
practitioner of veterinary
medicine having the following business address:
________________________________________________________.
3. I understand this ongoing
"veterinarian-client-patient relationship" to be a relationship in
which the veterinarian named in the preceding paragraph has assumed the responsibility
for making veterinary medical judgments regarding the health of the animal(s)
described above and the need for veterinary medical treatment of said animal(s),
and in which I, as owner and /or caretaker of the animal(s), have agreed to
follow the instructions of the veterinarian in relation to zoonotic diseases.
I verify the foregoing to be accurate. I make the foregoing statement
subject to the penalties of 18 Pa.C.S.A. 4904 (relating to un sworn falsification
to authorities). In witness of this, I have signed and dated the
verification below.
Signature of Owner /
Caretaker______________________________________________
Date_________________
Printed Name of Owner /
Caretaker___________________________________________________________________
Address of Owner /
Caretaker_______________________________________________________________________
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