Name of Owner (Print)

Telephone Number

Street Address

City, State, Zip

Animal Name

Sex

 Male      Female

Neutered

 Yes      No

Species

Age

Weight

Breed

Color(s)

The animal described above has been examined by me on: ________________ and I have determined that it would be medically contraindicated to vaccinate this animal due to an infirmity, other physical condition, or regimen of therapy.

Describe nature and duration of infirmity, other physical condition, or regimen of therapy:

PLEASE NOTE: A reluctance to administer a rabies vaccine prior to the expiration of the previous vaccination will not be accepted as a valid reason for an exemption.  Early boostering has not been associated with an increased occurrence of adverse reactions and is not medically contraindicated.

Name of Veterinarian (Print)

License Number

Address

Signature of Veterinarian

Date

This certificate is valid until

(not to exceed one year from date signed).

By signing below, I acknowledge that I am the owner of the animal described above. I have been informed that this animal is exempt from rabies vaccination for a period of up to one year.  I have also been informed of the following important information:

·         This animal must be re-examined by the expiration date listed above.  At that time the animal must either be vaccinated against rabies or, if exemption status still applies, a new certificate must be issued.

·         Once the duration of immunity from the last rabies vaccination has lapsed, this animal is not protected against rabies and, as a result, is at increased risk of becoming infected if exposed to a rabid animal.

·         It is recommended that the animal be closely observed when outside, walked on a leash and not allowed to run at large.  Prevent the animal from coming into contact with suspect rabid animals such as raccoons, skunks, foxes, groundhogs, bats and free-roaming cats.

• Exemption from rabies vaccination does not exempt the animal from other laws related to rabies. If this animal is potentially exposed to rabies (e.g., due to a bite or exposure from a rabid or suspect rabid animal), the local health agency will require it to be euthanized or quarantined for six months.  If this animal potentially exposes a person to rabies (by bite or other means), it must be confined for 10 days as approved by the local health agency where the animal resides.

Signature of Owner

Date Signed