Veterinary Certification Of Unfitness Of Dog Purchase - Free Download
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DateofExam:___________________________
OwnerofDogorCat:__________________________________________________________________________________
OwnerAddress:_________________________________________________________________________________________
OwnerTelephoneNumber:(______)___________________________________________________________________
AnimalSpecies:Canine___________Feline_______________
Breed:___________________________________________________________
Age:______________Sex:________________Color:________________
Diagnosis:________________________________________________________________________________________________
RecommendedTreatment:__________________________________________________________________________
______________________________________________________________________________________________________________
EstimateorActualCostofTreatment:___________________________
ThisistocertifypursuanttoArticle35‐DoftheGeneralBusinessLawoftheStateof
NewYork,thatIamaveterinariandulylicensedbytheStateof__________________,
thatIhaveexaminedtheaboveanimalassetforthhereinandthatIfindthatsaidani‐
malisunfitforpurchasedueto:(checkone)
_______illness
_______congenitalmalformationwhichadverselyaffectsthehealthoftheanimal
_______thepresenceofsymptomsofacontagiousorinfectiousdisease
SignatureofVeterinarian______________________________________________________Date:____________
NameofVeterinarian(printed):______________________________________________Lic#:____________
AddressofVeterinarian:_____________________________________________________________________________
PhoneNumberofVeterinarian:(______)__________________________
NewYorkStateDepartmentofAgricultureandMarkets
VeterinaryCertificationofUnfitnessofDogorCatForPurchase
DateofExam:___________________________
OwnerofDogorCat:__________________________________________________________________________________
OwnerAddress:_________________________________________________________________________________________
OwnerTelephoneNumber:(______)___________________________________________________________________
Diagnosis:________________________________________________________________________________________________
RecommendedTreatment:__________________________________________________________________________
______________________________________________________________________________________________________________
EstimateorActualCostofTreatment:___________________________
ThisistocertifypursuanttoArticle35‐DoftheGeneralBusinessLawoftheStateof
NewYork,thatIamaveterinariandulylicensedbytheStateof__________________,
thatIhaveexaminedtheaboveanimalassetforthhereinandthatIfindthatsaidani‐
malisunfitforpurchasedueto:(checkone)
_______illness
_______congenitalmalformationwhichadverselyaffectsthehealthoftheanimal
_______thepresenceofsymptomsofacontagiousorinfectiousdisease
SignatureofVeterinarian______________________________________________________Date:____________
NameofVeterinarian(printed):______________________________________________Lic#:____________
AddressofVeterinarian:_____________________________________________________________________________
PhoneNumberofVeterinarian:(______)__________________________
source: agriculture.ny.gov