Specialty Clinic Notification
The MVMA’s Practice Inspection and Practice Standards Bylaws require veterinarians to notify the MVMA about a specialty clinic prior to the event being held. Please note: As the MVMA begins its administrative work at the time of application, this fee is non-refundable.
Specialty Clinic Description
A specialty clinic is a type of veterinary practice that provides for i) the examination, diagnosis and/or treatment of animals, and/or ii) consultation with clients regarding their animals, on the basis of an off-premise event. To qualify for a specialty clinic the practice must also have a Small Animal Ambulatory Practice Inspection Certificate. A specialty clinic encompasses ophthalmology, preventative health and rabies clinics or other similar types of relevant practice. Two-weeks advance notice required. The sponsoring veterinarian must complete this form.
Sponsoring Practice/Clinic Information
Sponsoring Practice/Clinic that holds a Small Animal Ambulatory Practice Inspection Certificate
*
Sponsoring Veterinarian Name
*
First Name
Last Name
Sponsoring Veterinarian Email
*
example@example.com
Sponsoring Veterinarian Phone Number
*
Please enter a valid phone number.
Specialty Clinic Contact Information
Contact phone number for the Specialty Clinic
*
Please enter a valid phone number.
Contact fax number for the Specialty Clinic
Please enter a valid phone number.
Specialty Clinic Date(s) and Location
Description of where the Specialty Clinic will occur.
Date of Specialty Clinic
*
-
Month
-
Day
Year
Date
2nd Date of Specialty Clinic (if applicable)
-
Month
-
Day
Year
Date
3rd Date of Specialty Clinic (if applicable) * please note for an additional date you will need to complete another form)
-
Month
-
Day
Year
Date
Specialty Clinic Activities
Describe the type of event, service and/or procedures to be performed at this Specialty Clinic:
*
Declaration
As the sponsoring veterinarian of this specialty clinic, I have read and I am familiar with the Manitoba Veterinary Medical Association requirements and by-laws pertaining to the holding of a specialty clinic and I hereby consent to abide by and conform with all of the standards of practice for specialty clinics during the preparation and holding of the specialty clinic event detailed above. Further, I provide consent to the MVMA to publish any and all information contained in this application.
*
Yes
Signature
Date of application (Today's date)
*
-
Month
-
Day
Year
Date
Signature of Sponsoring Veterinarian
*
Clear
Fees and Payment Information
Please indicate what type of Specialty Clinic you are applying for:
*
Not-For-Profit - $42.00 ($40 + gst)
For-Profit = $84.00 ($80 + gst)
Please confirm how you will pay the fee.
*
I will pay by credit card below
I will send a cheque to the MVMA. I understand that my application cannot be approved until payment is received.
I understand that this fee is non-refundable as the MVMA begins the administrative work at the time the application is submitted.
*
Yes
The invoice and receipt should be made out to:
*
The Sponsoring Veterinarian
The Sponsoring Clinic
Please complete this section if paying by credit card
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Not-For-Profit Specialty Clinic
$40.00 + gst
$
42.00
CAD
For-Profit Specialty Clinic
$80.00 + gst
$
84.00
CAD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: