Exemption from Rabies Vaccination Form
Date of Exam: __________________
(This certificate is valid until ________________-NOT to exceed 3 years from date of issuance)
Owner name: __________________ ____________________ Phone #: (____) _______________
Street City State ZIP Code
Animal name: ___________________________ Species: ________________ Breed: _______________ Age: ______ Weight: _______ Color: ____________ Sex: [ ] Male [ ] Female Neutered: [ ] Yes [ ] No
Microchip Manufacturer: ________________ Microchip#: _____________________________
I have examined the animal above and determined it to be exempt from the local licensure requirements for rabies vaccination because this procedure is contraindicated due to the medical condition of the animal.
Describe nature and duration of health risk: ______________________________________________________________________________________
Veterinarian’s signature: ______________________________ License number: _________________
Printed name: ___________________________ Name of Practice: _____________________________
Street City State ZIP Code
By signing above, pursuant to Colorado Administrative Code, 6 CCR 1009-1, Section 8, I acknowledge that a valid veterinary-client-patient relationship, as defined under C.R.S. §12-64-103 (15.5), has been established between the veterinarian, owner and animal to be exempted from rabies inoculation. Duration of exemption is limited to the anticipated duration of the animal’s medical condition that precludes inoculation, not to exceed 3 years from date of issuance.
By signing below, I acknowledge that I am the owner of the animal described above. I have been informed that this animal is exempt from rabies vaccination for a period of up to three years, and also that I have been informed of the following important information:
§ This animal must be re-examined by the expiration date listed above. At that time, the animal must either be vaccinated against rabies or, if exemption still applies, a new certificate be issued.
§ This animal is not adequately protected against rabies, and as a result is at increased risk of becoming infected if exposed to a rabid animal
§ Exemption from rabies vaccination does not exempt the animal from other Colorado regulations and laws related to rabies. If this animal bites (or potentially exposes a person to rabies by other means), it must be confined for 10 days in a facility approved by the local health department where the exposure occurred. If this animal is potentially exposed to rabies (e.g. due to a bite from an unknown animal), the local health department may require it to be quarantined for 6 months, at the expense of the owner.
Owner’s signature: ____________________________________ Date signed: _________________
A copy of this certificate must be provided to the owner of the animal listed above and be kept as proof of exemption within the medical records of the animal. For dogs (and cats in some jurisdictions), this certificate must be presented with an application for a dog (or cat) license. Pursuant to Colorado Revised Statute 25-4-607, Section (3), (c): “A veterinarian supplying a waiver exempting an animal from a rabies vaccination, county and municipal health departments, their assistants and employees, the health department, health officers, and anyone enforcing this part 6 shall not be liable for any subsequent accident, disease, injury, or quarantine that may occur as a result of an animal exempted from a rabies vaccination pursuant to the rules of the health department.”
Verion: 01/19/2009. Available for download from Colorado Department of Public Health Environment, Disease Control and Environmental Epidemiology Division, Communicable Disease Epidemiology Program on rabies webpage: www.adphe.state.co.us/dc/zoonosis/rabies