ANIMAL OWNER VERIFICATION FORM

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.

Animal ID (ear tag, tattoo, leg band, etc.)

Registration Name or Description

2. I have an 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 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 18Pa.C.S.A. 4904 (relating to unsworn falsification to authorities). In witness of this, I have signed and dated this verification below.

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Signature of Owner/Caretaker Date

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Printed Name of Owner/Caretaker

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Address of Owner/Caretaker