Companion Animal Temporary/Specialty Clinic

I am applying for the following type of clinic*

Specialty Clinic (Non Surgical)Temporary Clinic (Surgical)

Sponsoring Practice/Clinic that holds a Small Animal Clinic/Hospital, Small Animal Mobile, and/or Small Animal Ambulatory Practice Inspection Certificate

Sponsoring Practice/Clinic that holds a Small Animal Ambulatory Practice Inspection Certificate

Name of veterinarian making the application*

First NameLast Name

Veterinarian Applicant Email address*

example@example.com

Contact Veterinarian:*

First NameLast Name

Contact Veterinarian Phone Number*

Please enter a valid phone number.

Event Location- Please provide full address or description below. Please note that applications that contain more than 1 location will be rejected.*

Services offered at this event:*

1st Date of Clinic*

Date

I understand that the last date of a clinic on this application can be no later than {iUnderstand56}

Yes

I understand that the last date of a clinic on this application can be no later than:

Date

I understand that dates that fall out of the time range above will be rejected and a refund will not be issued and you will be required to complete an additional application for dates outside of this range.*

Yes

2nd Date of Clinic (if applicable)

Date

3rd Date of Clinic (if applicable)

Date

4th Date of Clinic (if applicable)

Date

5th Date of Clinic (if applicable)

Date

6th Date of Clinic (if applicable)

Date

7th Date of Clinic (if applicable)

Date

I 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 above.

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.

8) {sponsoringPracticeclinic6} will not hold more than 7 Temporary Clinics within a 45 day period at this location.

Yes

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

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.*

Yes

Date of application (Today's date)*

Date

Signature of Sponsoring Veterinarian*

Please indicate what type of Clinic you are applying for:.*

Not-For-Profit - $47.25 ($45 + gst)For-Profit - $89.25 ($85 + gst)

Please confirm how you will pay the fee.*

I will pay by credit card belowI 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 VeterinarianThe Sponsoring Clinic

Please complete this section if paying by credit card

Not-For Profit Clinic

$45.00CAD

For-Profit Clinic

$85.00CAD

Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Companion Animal Temporary/Specialty Clinic Application

THIS FORM MUST BE SUBMITTED TWO WEEKS PRIOR TO THE STARTING DATE OF THE PROPOSED CLINIC

Sponsoring Practice/Clinic Information

Event Details

Please note that Temporary Clinics can only operate to serve and protect the public interest

Declarations

Signature

Fees and Payment Information