A Pawsitive Experience requires a Health Exam, vaccines and indicated fecal testing before assessment.  Exam must be within 30 days of first appearance - no less than 10 days.  Have your Vet fill in EACH line of the the form completely & INITIAL EACH LINE.  Fax copy and return ORIGINAL to A Pawsitive Experience.

  CERTIFICATE MUST BE EXECUTED IN FULL  BEFORE DOG IS ALLOWED ON PROPERTY

(Insert Vet Stamp with Name and Address to your right )

Owner:

Dog:

Address:

Breed/Sex:

City:

Birth Date & Age Now:

Phone:

Color:

DATE GIVEN

VET  INITIALS*

NOTES

DAP (per vet recommendation)

RABIES (per state rqmts)                                            

CANINE COUGH  (Annual)

OTHER (Flea Check & Nails Clipped (mandatory)

*Vet Note:  Vaccines at your discretion. Indicate Titer results, vaccines given/withheld and why.  Vet’s initial required in each space.

DATE TESTED

VET  INITIALS

RESULTS, NOTES & RX

Parasites & Coccidia

Giardia (SNAP or ELISA TEST only accepted)

DATE TESTED

VET  INITIALS

RESULTS, NOTES & RX

Heartworm Test (8 months & older) Initial Test Annually thereafter if not on monthly March thru November

LEPTO Vaccine (only if high risk and vet recommended)

CANINE FLU (Vaccinate @ vet and client option)

I certify that (1) I have (within the last 30 days) examined and tested this patient as indicated above and: found them to be in good health, free of signs of infectious diseases, parasites including but not limited to fleas, lice, diarrhea, coughing, nasal drip or conjunctivitis on this date AND/OR (2) This is a special needs dog requiring the following: _____________________

____________________________________________________________________.

___________________________, DVM      Dated this_____ day of ____________, 2010

                (Vet Signature)