Vaccination Waiver Request

Date                                       

Caretaker’s Name                                                                                                   

Address                                                                                                                    

Dog’s Name____________________ Sex            Breed                                     

Birthdate ________________ Color                                                           


I certify that I have examined the animal described. To the best of my knowledge and belief,
the statements indicated below are true.  This dog is:
 
_____ Free from infectious, contagious and/or communicable disease for the past _________ days/months.
 
_____  In good physical condition.
 
_____  The dog’s caretaker states no known exposure to rabies or other communicable diseases in

the past _________ days/months.

 
_____  The county of residence is not under a rabies quarnatine.
 
_____  The caretaker states that the animal has not bitten anyone within the last 10 days.
 
_____  I recommend that this animal be exempt from the requirement for rabies vaccination because the rabies

vaccines, as instructed by the vaccine manufacturers, are for use in healthy animals only.

 
____ The animal named above is not considered to be healthy because this animal is currently in treatment for

the following medical condition: ______________________.

 
____ The animal named above has had an anaphylactic reaction to a prior rabies vaccination and further

vaccination could result in serious illness or death.

 
 
___________________________________     ____________________     ____________
Veterinarian’s Signature                                                        License Number                                Date
 
     
* Form prepared by JanGen Press and the Magic Bullet Fund to protect dogs with cancer.