Vaccination Waiver Request


Caretakerís Name                                                                                                   


Dogís Name____________________ Sex            Breed                                     

Birthdate ________________ Color                                                           

I certify that I have examined the animal described. To the best of my knowledge and belief,
the statements indicated below are true.  This dog is:
_____ Free from infectious, contagious and/or communicable disease for the past _________ days/months.
_____  In good physical condition.
_____  The dogís caretaker states no known exposure to rabies or other communicable diseases in

the past _________ days/months.
_____  The county of residence is not under a rabies quarnatine.
_____  The caretaker states that the animal has not bitten anyone within the last 10 days.
_____  I recommend this animal be exempt from the requirement for rabies vaccination because the rabies

vaccines, as instructed by the vaccine manufacturers, are for use in healthy animals only.
____ The animal named above is not considered to be healthy because the animal is currently in treatment for the following medical condition: ______________________.
____ The animal named above has had an anaphylactic reaction to a prior rabies vaccination and further

vaccination could result in serious illness or death.
___________________________________     ____________________     ____________
Veterinarianís Signature                                                        License Number                                Date
* Form prepared by JanGen Press and the Magic Bullet Fund to protect dogs with cancer.