Veterinary Evaluation

Please complete the form below.

Please enable JavaScript in your browser to complete this form.

THERAPY DOG VETERINARY EVALUATION

Canine Link, Inc. is a New York not-for-profit corporation whose primary purpose is the provision of therapy dog services to schools, health facilities and other institutions.

Canine Link, Inc. (“Link”) requires initial certification and annual recertification of each Link therapy dog’s suitability for therapy work, including an evaluation of the dog’s health by the dog’s veterinarian on this form. Please provide the information requested under “OWNER AND DOG” below and sign and date in the space provided and have your dog’s veterinarian provide the information and sign and date in the space provided under “VETERINARIAN AND EXAMINATION RESULTS” below. If there are any questions regarding completion of this form, please call Link at (855) 595-4651. You must submit this completed and signed form as a condition to certification and, if for a recertification, at least one month before expiration of your dog’s current certification. Please mail the completed and signed form to Canine Link at PO Box 900, Sheffield, MA,01257 or scan it as a PDF and email it to Link at caninelinktherapydogs@gmail.com. Please do not submit it more than once unless requested.

PLEASE be sure to keep a copy of this completed form for your own records and be sure to bring a copy with you on every visit to any facility as a Link volunteer with your dog, as you may be asked to show evidence of your dog’s health.

OWNER AND DOG

Owner's Name

First

Last

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Telephone

Cell

Fax

Confirm Email

Dog's Name (call name, not AKC or other registry name)

Breed (if not known, best guess as to mix)

Gender

Male
Female

Is Your Dog Spayed/Neutered?

Date Of Birth

Weight

My dog described above is currently protected from fleas and ticks by an appropriate repellent or other parasite control regime and I use it in accordance with the manufacturer’s or my veterinarian’s instructions. I am not aware of any unresolved medical or behavioral problems that should be a source of concern if my dog were to serve as a therapy dog in a school, hospital or other institution.

Signature

Date

VETERINARIAN AND EXAMINATION RESULTS

Examining Veterinarian: Please complete the following and sign and date this form in the space below; Link thanks you for your cooperation.

Name Of Clinic/Hospital

Examining Veterinarian

First

Last

License #

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Telephone

Fax

Confirm Email

Owner's Name

First

Last

Dog's Name (call name, not AKC or other registry name)

Most Recent Rabies Vaccination (current vaccination required):

Rabies Vaccination

Date Of Rabies Vaccination

Expires

Most Recent Bordetella Vaccination (current vaccination required):

Rabies Vaccination (copy)

Date Of Bordetella Vaccination

Expires

Most Recent Fecal Tests (required thirty (30) days):

Test Date

Results

Negative
Positive

If Positive, Please Describe And Comment Below:

Please List Any Other Current Vaccinations Below:

Vaccinations

Vaccination

Date

Expiration Date

Please make an overall physical examination of the dog, including ears, eyes, nose and throat, integument, auscultation, abdominal palpation, urogenital and lymph nodes. Please state if your examination revealed anything that would be a source of concern if the dog were to serve as a therapy dog in a school, hospital or other institution, such as fever, open sores, diarrhea, vomiting, coughing or sneezing, ticks, fleas or other external parasites, dermatitis, otitis or seizure or other neurological disorder and, if so, whether the concern has been resolved:

Overall Physical Examination Comments

Is the dog generally in good health and well-groomed with appropriately trimmed nails?

Comments

Examining Veterinarian’s Signature:

Date