Companion Animal Temporary Clinic Application
The MVMA’s Practice Inspection and Practice Standards Bylaws require veterinarians to notify the MVMA about a temporary 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.
Companion Animal Temporary Clinic Description
Companion Animal Temporary Clinic license allows for the provision of veterinary services to communities while maintaining professional and practice standards, thus protecting the public. The intent of the surgical component of the Companion Animal Temporary Clinic is to make elective surgeries available in areas requiring these services. A separate application is required for each clinic.
Clinics are a maximum of 7 consecutive days for duration. THIS FORM MUST BE SUBMITTED TWO WEEKS PRIOR TO THE STARTING DATE OF THE PROPOSED CLINIC
Event Sponsors
Name of veterinarian making the application for a Companion Animal Temporary Clinic
*
First Name
Last Name
Sponsoring Practice/Clinic that holds a Small Animal Clinic/Hospital, Small Animal Mobile, and/or Small Animal Ambulatory Practice Inspection Certificate
*
Contact Veterinarian:
*
First Name
Last Name
Contact Veterinarian Phone Number
*
Please enter a valid phone number.
Event Details
Description of Event Location
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1st Date of Temporary Clinic
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Month
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Day
Year
Date
2nd Date of Temporary Clinic (if applicable)
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Month
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Day
Year
Date
3rd Date of Temporary Clinic (if applicable)
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Month
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Day
Year
Date
4th Date of Temporary Clinic (if applicable)
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Month
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Day
Year
Date
5th Date of Temporary Clinic (if applicable)
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Month
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Day
Year
Date
6th Date of Temporary Clinic (if applicable)
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Month
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Day
Year
Date
7th Date of Temporary Clinic (if applicable)
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Month
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Day
Year
Date
Please note that Temporary Clinics can only operate to service and protect the public interest
Declarations
I can confirm the following: 1) I am currently licensed to practice veterinary medicine in the Province of Manitoba and am currently associated with a facility licensed as a Small Animal Clinic/Hospital, Small Animal Mobile Clinic, and/or Small Animal Ambulatory. 2) The equipment and supplies that are to be taken to the community have been inspected and are currently certified and compliant as part of the PIPS inspection of the Small Animal Clinic/Hospital practice as named in (1). 3) The structure from where the veterinary services are to be provided will properly serve the public so that there is adequate lighting, ventilation, heating/cooling, cleanliness and accessibility. 4) Adequate post-operative care is provided. This requires the attending veterinarian to remain in the community for a minimum of 12 hours after completion of the last surgical procedure. Following this period, the attending veterinarian or another veterinarian from their practice, must be reasonably available for telephone consultation/follow-up for at least 4 weeks following each visit. 5) The veterinarian or delegate will coordinate appointments and provide contact with the attending veterinarian between visits. 6) Adequate commercial liability insurance is carried. 7) I provide consent to the MVMA to publish any and all information contained on the Temporary Clinic application.
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Yes
Signature
I understand that the provision of false information in any part of this document is professional misconduct. I hereby certify that all the information contained herein is true, correct and complete.
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Yes
Date of application (Today's date)
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Month
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Day
Year
Date
Signature of Sponsoring Veterinarian
*
Clear
Fees
Please indicate what type of Temporary Clinic you are applying for:.
*
Not-For-Profit - $36.75 ($35 + gst)
For-Profit - $78.75 ($75 + 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 Temporary Clinic
$35.00 + gst
$
36.75
CAD
For-Profit Temporary Clinic
$75.00 + gst
$
78.75
CAD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: