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Faithful Paws   at   Bellaire United Methodist Church

                    ANIMAL ASSISTANCE THERAPY PROGRAM
         INITIAL HEALTH RECORD - DOG  

             (Print out, have vet fill out, and turn in at time of certification)



Name of Owner: ___________________________________  Date: ______________

 

Name of Animal ___________________________ Breed ______________________

 

Immunizations                                                          DATE


Rabies                                     Y     or     N           __________________________ 


Distemper                                Y     or     N           __________________________

 

Hepatitis                                  Y    or     N            __________________________

 

Leptospirosis                           Y    or      N           __________________________

 

Parainfluenza                          Y    or     N             __________________________

 

Parvovirus                               Y     or    N            __________________________

Fecal Clear                              Y      or    N           __________________________


Heartworm Clear                     Y     or     N           __________________________

 

Ears  Clear                              Y      or    N           __________________________

 

If No, what type of medications for treatment: ________________________________

Comments: ____________________________________________________________

 

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

 

Signature of licensed veterinarian________________________________________

 

Address_____________________________________ Date____________________

 

___________________________________________  Phone___________________

address stamp of veterinarian here: