Fairfax Pets On Wheels Health CertificateDate of
Rabies: _______________________ Animal Name:_____________________________________________ Age: ________________ Species:_________________ Wt: _________ Sex: M F N S (Circle One) Breed/Type: _____________ Color: _______________ I hereby certify that I have examined the above described animal on ________________ (date) and find same to be free from visible symptoms of contagious, infectious, communicable disease, internal parasites, and this pet has the current vaccinations I recommend for this species. I know of no medical reason this pet is not suitable for nursing home/hospital visitation. Veterinarian Signature:_______________________________________ License #: ________________________________ Animal Hospital
Name and Address and Telephone (Stamp): _______________________________________ _______________________________________ Animal Owner Name:_______________________________________ Address: ______________________________________________________________ Contact Phone #: __________________ FPOW Volunteer Name (if different from owner): _______________________________________ Contact
Phone #: __________________ |