Puppy Veterinary Information Form

Puppy Class Veterinary Information Form

Fairfax Campus
This form must be completed and submitted by a licensed veterinarian.

Please note all vaccinations must be admisistered by a licensed veterinarian or member of their staff. Vaccines administered by a breeder or rescue operation will not be accepted for admittance to our puppy classes.

Please email this form to the veterinary office where your pet's vaccinations were administered. Please request that the form be filled out and submitted to us. Please keep in mind that veterinary clinics are busy places, and the completion of this form may take several days or more. Please remember to be respectful of their time.

The origin of completed forms will be confirmed for accuracy. You will receive a confirmation from ABWC upon receipt of your completed form.
Owner Information
Owner Name*

First NameLast Name
Owner Email*
example@example.com
Puppy Information
Pet (patient) Name*
DOB or Age of Pet:*
I   First Name*   Last Name*   , the undersigned veterinarian or authorized staff member, hereby confirm that I have examined the above listed puppy and have deemed him/her healthy and free of transmissible diseases as of this date   Date* .
Initials :   Initial Here*

I, the undersigned veterinarian or authorized staff member, hereby confirm that the puppy will have lived in the listed owner’s home, to the best of my knowledge, for 8 days as of this date  Date* .
Initials :      Initial Here*

I , the undersigned veterinarian or authorized staff member, hereby confirm that I (or an authorized member of my staff) vaccinated the puppy with a distemper and parvo combination vaccine on this date   Date*.
Initials :  Initial Here*

I , the undersigned veterinarian or authorized staff member, hereby confirm that I (or an authorized member of my staff) vaccinated the puppy with a Bordetella vaccine on this dateDate*.
Initials :   Initial Here*

I, the undersigned veterinarian or authorized staff member, hereby confirm that I (or an authorized member of my staff) have completed a negative fecal test for this puppy on this date Date*.
Initials :
Initial Here *
Comments:
Veterinarian Signature*

Clear
Date*

MonthDayYear
Date
Clinic Name *
This form must be submitted by the veterinary clinic listed above. Please submit from the clinic or hospital's email address so origin can be verified.
Email Validator*
Should be Empty:

Puppy Class Veterinary Information Form

Owner Information

Puppy Information