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Dog Health Screening Form

Dear Veterinary Professional,

One of your animal clients is interested in becoming a member of the Chris Center’s PAWS Wellness Support Program, a program that trains, evaluates, and registers volunteers and their dogs visiting teens in schools and other settings. The program is distinguished by its attention to training the volunteers, evaluating teams every two years, and having awareness of the health of the animals. By having a systematic process for registering teams, we minimize risk to the patients who are visited by the teams and respect the health and well-being of the animals who participate in the program.

You are being asked to complete the Dog Health Screening Form on behalf of the applicant. Based on your medical judgment and knowledge of the animal’s history and current status, please assess if the animal meets the health criteria for our program. You will find the requirements outlined in the following form.

For animals with disabilities: If you believe the animal is physically able to participate in the program, please provide any necessary accommodations on the Animal Health Screening Form or attach a separate letter on letterhead, if more room is required. If otherwise healthy, animals with a disability can have a positive impact on special populations, providing their activities do not exacerbate the animal’s disability.

As this animal’s veterinarian, you are the best person to render the overall opinion of the animal’s health. It is important to consider that visiting animals may both be exposed to infectious agents because they visit people in healthcare facilities and be a potential source of infectious agents for people they visit. We realize an examination cannot detect all potential problems and that changes to an animal’s health status can occur after the veterinary examination. The Chris Center is not expecting a guarantee that no risks are present, simply your assessment of the animal at the time of your examination.

Thank you for your time.

With gratitude,

The Chris Center PAWS Team

March 12, 2025

First Veterinary Professional's Name

First Name*

Last Name*
First Veterinary Professional's Age Acknowledgment*
First Veterinary Professional's Date of Birth*
I certify that I am 18 years of age or older
First Veterinary Professional's Signature*
Second Veterinary Professional's Name

First Name*

Last Name*
Second Veterinary Professional's Date of Birth*
Third Veterinary Professional's Name

First Name*

Last Name*
Third Veterinary Professional's Date of Birth*
Fourth Veterinary Professional's Name

First Name*

Last Name*
Fourth Veterinary Professional's Date of Birth*
Fifth Veterinary Professional's Name

First Name*

Last Name*
Fifth Veterinary Professional's Date of Birth*
Sixth Veterinary Professional's Name

First Name*

Last Name*
Sixth Veterinary Professional's Date of Birth*
Seventh Veterinary Professional's Name

First Name*

Last Name*
Seventh Veterinary Professional's Date of Birth*
Eighth Veterinary Professional's Name

First Name*

Last Name*
Eighth Veterinary Professional's Date of Birth*
Ninth Veterinary Professional's Name

First Name*

Last Name*
Ninth Veterinary Professional's Date of Birth*
Tenth Veterinary Professional's Name

First Name*

Last Name*
Tenth Veterinary Professional's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Additional Information

Dog Owner's Name

Dog’s Name:

Dog’s Breed:

Dog’s Year of Birth:

As the dog’s veterinarian, you are the best person to render the overall opinion of the animal’s health. If this animal has received an annual exam within the last 12 months, this form may be completed without another full examination.

Based on my examination, this dog meets the health criteria listed below:
This dog is current on rabies vaccinations.
This dog is free of internal and external parasites at the time of examination.
This dog does not display any signs consistent with an infectious disease at the time of examination.
If this dog has a condition, it is under control using a prescribed medication. (Please note: Animals currently taking antibiotics, antifungals, or immunosuppressive medications are not able to participate.)
If this dog has a disability, it can still participate fully with accommodations. Please include suggested accommodations below.

I certify that this dog meets all the health criteria outlined by the Chris Center. 


DVM Name:

Clinic Name:

Clinic Website:

Clinic Address:

Phone #:

Email Address:

Examination Date:
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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