Denalicoons Maine Coon Cattery
Richard and Valerie Johnston, P. O. Box 111065, Anchorage
AK 99511-1065
REFERENCE QUESTIONNAIRE AND AUTHORIZATION/RELEASE
I, ________________________________________ , the undersigned hereby
give permission for any veterinarian, veterinary technician, veterinary
clinic, animal hospital, or authorized representative or agent there of
to provide truthful and accurate answers, to the best of the individual's
knowledge, to the questions listed below my signature on this document.
I understand that all responses to these questions will be kept confidential,
strictly between the individual completing this questionnaire and Richard
and/or Valerie Johnston, breeders. The purpose of this questionnaire is
to provide a background reference for the breeders' consideration in determining
whether or not to sell a purebred Maine Coon Cat/Kitten to me. Further,
I agree to hold the veterinarian, veterinary technician, veterinary clinic,
animal hospital, or authorized representative or agent there of harmless
for any answers provided and understand that I am not entitled to review
any response made in reference to this questionnaire and authorization/release.
This authorization expires one hundred and eighty (180) days from the date
of signature. Copies, either by FAX or by "xerox" process will be accepted
the same as an original.
_________________________________________________ __________________________________
Signature of individual:
Date of authorization:
QUESTIONNAIRE
-
Has the individual had animals treated by you or your clinic? _____YES
_____ NO
If so, for about how long? ______________ Years _____________ Months
-
Has the individual maintained the necessary vaccinations? _____YES _____
NO
-
Has this individual maintained a routine preventative exam and treatment
schedule on the animals you have cared for? _____YES _____ NO
-
Has the individual presented any animal for treatment of injury or illness
that you could reasonably consider the result of abuse or neglect? _____YES
_____ NO
-
Has this individual had any major disease outbreak -- such as Feline Leukemia
or Feline Infectious Peritonitis? _____YES _____ NO If so, how long ago
and what was the course of treatment (i.e. euthanasia, long term clinical
treatment, consultation with outside or other veterinary sources.) [BRIEF
STATEMENT]
Did the individual follow what you consider a reasonable and prudent
approach to the situation? _____YES _____ NO
_________________________________________________ __________________________________
Signature of individual completing questionnaire:
Date of completion: