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<br />NORTH CAROLINA DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES <br />VETERINARY DIVISION <br />1030 Mail Service. Center <br />Raleigh, NC 27699' 1030 <br />Telephone: (919) 733'7601 <br /> <br />ANNUAL PROGRAM OF VETERINARY CARE <br /> <br />BUSINESS: <br />OWNER: <br />MANAGER: <br /> <br />TELEPHONE: <br />COUNTY: <br /> <br />VETERlNARIAN: <br />ADDRESS: <br /> <br />TELEPHONE: <br /> <br />City/State/Zip <br /> <br />This form is to be used for documenting the program for veterinary care in animal facilities. Items below are to be completed' <br />with the assistance of a veterinarian licensed by the State of North Carolina. If space is not adequate, use the back of the <br />page or attach additional page(s). This form is to be signed by the owner or manager of the facility and the <br />veterinarian. .' . . . <br /> <br />I. DISEASE PREVENTION and CONTROL: The facility and primary enclosures are to be cleaned daily, as per <br />regulations NCAC 52J..o2.o5, .02.07). Describe your procedures for diSinfecting; (1) Primary enclosures, (2) <br />Feed/water bowls, and (3) Bedding, if provided. <br /> <br />II. VACCINATIONS/PARASITE CONTROL: Rabies vaccination is required according to NC rabies laws. List any other <br />vaccinations you require. Specify age and species. <br /> <br />III. MEDICAL RECORD$:Describe how treatments, medications, and immunizations are documented. <br /> <br />IV.' ISOLATION: Describe your provisions and procedures for isolation of incoming and/or sick animals. <br /> <br />V. PROTOCOL FOR SALE/ADOPTION OF DISEASED OR DEFORMED ANIMALS: <br /> <br />VI. EMERGENCY VETERINARY CARE: Protocol for providing emergency veterinary care. <br /> <br />VII. EUTHANASIA: If applicable, person responsible for euthanasia: <br />Name: Telephone L-l <br />First Last <br />Method of euthanasia: <br /> <br />I certify that the facility named above has implemented this program of veterinary care and that the veterinarian named above <br />assisted with its development. . <br /> <br />Facility Owner or Manager (signature required) <br /> <br />Date <br /> <br />As the veterinarian listed on this form, I have discussed these areas of the program of veterinary care with the owner. I am <br />not responsible for any procedures implemented or the direct care.of animals at this facility: Veterinary care is provided to <br />animals on request of the facility owner/manager. <br /> <br />Veterinarian (signature required) <br /> <br />License # <br /> <br />Date <br /> <br />NOTE: NCDA&CS, Veterinary Division shall be notified in writing if the veterinarian!client relationship is terminated. <br />AW-1.2005 G- 5 <br />