Vaccination Waiver Request
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.