Home » Test Dollars Pet Health Form (filled out by Vet) Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Dear Health Care Provider, the pet below is applying to be a therapy animal for visits to schools, nursing homes, etc. Please complete this form in its entirety. Alternatively, you can access a PDF version here. If you have issues/questions, contact Karen Clark at kclark@ccpettherapy.org | 973-285-9083 ext. 202. Veterinary InformationPractice Name *Practice Phone Number *Practice E-mail * Veterinarian First Signature Veterinarian First and Last Name *Veterinarian Licence Number *Pet InformationOwner's First and Last Name *Pet's Name *Pet Breed *Pet Type *Dog, CatHorseGoatRabbit, Guinea Pig, FerretOtherDate of last examDue Date of Rabies Vaccine / TiterRabies Tag NumberDue Date of Distemper Vaccine / TiterDate of Last Fecal ExamA fecal test with a negative result must have been performed within the last yearDue Date of CogginsDue Date of Clostridial Vaccine (CDT)General CommentsSignatureElectronic Signature of Veterinarian: *I confirm that the details provided in this form accurately reflect the pet’s medical history. Our practice has personally examined the pet listed above and can attest that it is in good physical and mental health and shows no signs of contagious illness.Submit
