Name___________________________________________                                                                                                                                                                   .                                              Animal Owner or Caretaker’s Verification of Veterinarian-Client-Patient Relationship                                                            I am the undersigned, hereby verify the following:      I am the owner/caretaker (circle one or both) of the following animal(s), identified by ear tag, tattoo, leg band, etc. (A copy of the                                                            “Certificate of Veterinary Inspection” may be attached to meet this animal identification requirement. Use additional sheets as necessary.)
ANIMAL ID 
                         (i.e. ear tag, tattoo, leg band, brand)	REGISTRATION NAME OR DESCRIPTION	

		

		

		

		

		
I have established an ongoing “Veterinarian-Client-Patient Relationship” for the animal(s) described in the preceding paragraph with ________________________________________   (print name), a licensed practitioner of veterinary medicine having the following business address: ____________________________________________________________________
I understand this ongoing “Veterinarian-Client-Patient Relationship” to be a relationship in which the veterinarian named in the preceding paragraph has assumed the responsibility for making veterinary medical judgments regarding the health of the animal(s) described above and the need for veterinary medical treatment of said animal(s), and in which I, owner and/or caretaker of the animal(s), have agreed to follow the instructions of the veterinarian in relation to zonotic diseases.
I verify the foregoing to be accurate. I make the foregoing statement subject to the penalties of 18 Pa.C.S.A. § 4904 (relating to unsworn falsification to authorities). In witness of this, I have signed and dated this verification below.
_____________________________________________________________________           ________________________________________________________________________ Signature of Owner/Caretaker                                                                   Date                                                        Printed Name Of Owner / Caretaker                                          .                    ________________________________________________________________________________________________________________________________________________    Address of Owner/Caretaker