Sample Veterinarian/Patient/Client Relationship Confirmation Form

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Veterinary
Herd Health
Program
Lakeview Animal Clinic
117 E. Second Street
Lakeview, MI 48850
Veterinary Client Patient Relationship
2015
The Veterinary Client Patient Relationship establishes the responsibilities of the
veterinarian and the client / producer, regarding the medical decisions of the patient /
producer’s herd and individual animals.
The veterinarian will assume all the medical responsibility of the producer’s herd. To do
so, the veterinarian must be personally familiar with the medical care of the animals, the
management of the herd and the facilities. The veterinarian will be physically on the
farm, on a regular basis, and in direct contact with the animals. The veterinarian will
perform physical examinations and diagnostic testing. The veterinarian will establish the
diagnosis of disease, both at the individual animal and herd level. The veterinarian will
then prescribe treatment for the disease. The veterinarian will establish disease prevention
programs for the herd. The veterinarian will be readily available for consultation for such
events as an adverse drug reaction or a failure of treatment. The veterinarian will be
readily available to respond to a follow-up visit to the farm to perform a prompt
reevaluation of the diagnosis and treatment protocols. The veterinarian will be available
to respond to a farm visit for any emergency situation. The veterinarian will be
responsible for all prescription drug purchases and reviewing the producer’s drug
inventory and drug disposal records. The veterinarian will establish the physical
examination, treatment, and prevention protocols and review the producer’s treatment
records.
The producer is responsible to follow the medical advice of the veterinarian.
________________________________________________________________________
Producer:
______________________
______________________
______________________
Farm name: ______________________
Address:
______________________
______________________
Veterinarians: Steve Edwards DVM
Karen Peterson DVM
Erin Shaw DVM
Lakeview Animal Clinic
117 E. Second St.
Lakeview, MI 48838
We hereby certify that a valid Veterinary / Client / Patient Relationship ( VCPR )
is established between the Producer and the Veterinarian.
________________________ _______
Producer’s signature
Date
_______________________
Veterinarian’s signature
_______
Date
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