Form DBPR VM4 "Limited-Service Veterinary Medical Practice Clinic Registration - Board of Veterinary Medicine" - Florida

What Is Form DBPR VM4?

This is a legal form that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2013;
  • The latest edition provided by the Florida Department of Business & Professional Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DBPR VM4 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

ADVERTISEMENT
ADVERTISEMENT

Download Form DBPR VM4 "Limited-Service Veterinary Medical Practice Clinic Registration - Board of Veterinary Medicine" - Florida

Download PDF

Fill PDF online

Rate (4.4 / 5) 97 votes
1 of 4
State of Florida
Department of Business and Professional Regulation
Board of Veterinary Medicine
Application for a Limited-Service Veterinary Medical Practice Clinic Registration
Form # DBPR VM 4
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION REQUIREMENTS
A LL Applicants must submit:
 Complete this application.
 Fees:
 $25 for each limited-service medical practice clinic registration.
 Make check payable to the Florida Department of Business and Professional Regulation.
 Each limited service clinic must be registered with the Florida Department of Business and
Professional Regulation by name, address, date of clinic, time and duration at least 28 days prior to
offering the clinic.
 The registration is valid through May 31 of each year, regardless of when the clinic was operational.
 Read Rule 61G18-15.007, Florida Administrative Code, which outlines the minimum standards for a
limited service practice.
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Limited-Service Veterinary Medical Practice
A limited-service veterinary medical practice clinic is where a veterinarian performs vaccinations and/or
immunizations against disease on multiple animals and where the veterinarian may also perform
preventative procedures for parasitic control.
MINIMUM STANDARDS FOR LIMITED-SERVICE VETERINARY MEDICAL PRACTICES
See Rule 61G18-15.007, 61G18-15.0071 and 61G18-15.0072 Florida Administrative Code
for more
information.
All locations where limited-service veterinary medicine is practiced must comply with the following:
1. Legible sign to identify permit holder and legible sign to identify veterinarian on site by name and
license number.
2. Clean safe location conducive to handling animals and consultations with the public.
3. Meet local sanitation requirements.
4. Display a copy of the limited-service clinic premise permit.
5. Provide a list of the name, address and hours of operation of all facilities that provide or advertise
emergency services, that are located within a 30-minute or 30-mile radius.
6. Lined waste receptacle.
7. A sink with fresh, clean running water for cleaning and first aid, disposable towels and soap within ten
feet of the examination area. Sinks located in restrooms may not be used to satisfy this requirement
8. Safe, clean examination work area constructed of a smooth impervious material.
9. Storage of supplies and equipment to preclude public access.
10. Separate area for clerical work.
11. Proper handling of vaccinations, biologics, pharmaceuticals and supplies:
a. Facilities must be provided for proper storage, safekeeping and preparation of pharmaceuticals in
accordance with federal, state and local laws.
b. Controlled substances must be kept in a locking, secure cabinet for storage.
c. Accurate controlled substance log must be maintained.
d. All pharmaceuticals and biologics maintained at the temperature recommended by the
manufacturer in a refrigeration device that is powered by a stable energy source and is capable of
maintaining a constant temperature.
12. Equipment must be of the type and quality to provide for the delivery of immunization and
parasiticides in the best interest of the patient and with the safety of the public.
DBPR VM 4
Eff. Date April 2013
Incorporated by Rule: 61-35.025
1 of 4
State of Florida
Department of Business and Professional Regulation
Board of Veterinary Medicine
Application for a Limited-Service Veterinary Medical Practice Clinic Registration
Form # DBPR VM 4
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION REQUIREMENTS
A LL Applicants must submit:
 Complete this application.
 Fees:
 $25 for each limited-service medical practice clinic registration.
 Make check payable to the Florida Department of Business and Professional Regulation.
 Each limited service clinic must be registered with the Florida Department of Business and
Professional Regulation by name, address, date of clinic, time and duration at least 28 days prior to
offering the clinic.
 The registration is valid through May 31 of each year, regardless of when the clinic was operational.
 Read Rule 61G18-15.007, Florida Administrative Code, which outlines the minimum standards for a
limited service practice.
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Limited-Service Veterinary Medical Practice
A limited-service veterinary medical practice clinic is where a veterinarian performs vaccinations and/or
immunizations against disease on multiple animals and where the veterinarian may also perform
preventative procedures for parasitic control.
MINIMUM STANDARDS FOR LIMITED-SERVICE VETERINARY MEDICAL PRACTICES
See Rule 61G18-15.007, 61G18-15.0071 and 61G18-15.0072 Florida Administrative Code
for more
information.
All locations where limited-service veterinary medicine is practiced must comply with the following:
1. Legible sign to identify permit holder and legible sign to identify veterinarian on site by name and
license number.
2. Clean safe location conducive to handling animals and consultations with the public.
3. Meet local sanitation requirements.
4. Display a copy of the limited-service clinic premise permit.
5. Provide a list of the name, address and hours of operation of all facilities that provide or advertise
emergency services, that are located within a 30-minute or 30-mile radius.
6. Lined waste receptacle.
7. A sink with fresh, clean running water for cleaning and first aid, disposable towels and soap within ten
feet of the examination area. Sinks located in restrooms may not be used to satisfy this requirement
8. Safe, clean examination work area constructed of a smooth impervious material.
9. Storage of supplies and equipment to preclude public access.
10. Separate area for clerical work.
11. Proper handling of vaccinations, biologics, pharmaceuticals and supplies:
a. Facilities must be provided for proper storage, safekeeping and preparation of pharmaceuticals in
accordance with federal, state and local laws.
b. Controlled substances must be kept in a locking, secure cabinet for storage.
c. Accurate controlled substance log must be maintained.
d. All pharmaceuticals and biologics maintained at the temperature recommended by the
manufacturer in a refrigeration device that is powered by a stable energy source and is capable of
maintaining a constant temperature.
12. Equipment must be of the type and quality to provide for the delivery of immunization and
parasiticides in the best interest of the patient and with the safety of the public.
DBPR VM 4
Eff. Date April 2013
Incorporated by Rule: 61-35.025
2 of 4
13. Each limited-service clinic must have the capacity to render emergency care for hypersensitivity
reaction, anaphylaxis and immediate emergency care of injury to the animals in attendance at the
clinic.
14. Sanitation equipment and solutions.
15. Proper bio-medical waste handling equipment, registration and procedures.
16. Clinics held for longer than four hours in any one day for any single location within the two week
period must meet the following:
a. The limited service clinic must be held inside a climate controlled building which meet all local
building and life safety ordinances;
b. The limited service clinic provider has been operating in such capacity in this State for no less
than five years.
c. The limited service clinic provider has not had their license either suspended or revoked in this or
any other state;
d. The limited service clinic provider possesses professional liability coverage in the amount of
$1,000,000 for each occurrence and $2,000,000 in the aggregate as well as an umbrella policy of
$3,000,000 for each occurrence and $3,000,000 in the aggregate.
e. All information required must be made available in electronic format within 24 hours of operation.
f.
The following information must be posted on, or adjacent to, the entrance of the building where
the clinic was held for forty-eight hours after the conclusion of the clinic:
i.
The telephone number where emergency veterinary care can be obtained;
ii.
The name and address of where a client can secure a copy of the patient’s records;
iii.
A phone number for consultation or referral for follow-up care and treatment in case of
adverse reaction or failure of the regimen of therapy.
DBPR VM 4
Eff. Date April 2013
Incorporated by Rule: 61-35.025
3 of 4
State of Florida
Department of Business and Professional Regulation
Board of Veterinary Medicine
Limited-Service Veterinary Medical Practice Clinic Registration
Form # DBPR VM 4
[2607/1030]
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
For additional information see the Instructions at the end of this application.
USE A SEPARATE PAGE FOR EACH LOCATION
Section I – Permit Holder Information
LIMITED-SERVICE VETERINARY MEDICAL PRACTICE PERMIT HOLDER INFORMATION
Permit Holder Name:
Permit Number:
Section II – Clinic Information
CLINIC INFORMATION
Location Site/Name:
Street Address
City
State
Zip Code (+4 optional)
Do you plan to hold the clinic for longer than four hours?
 Yes
 No
If “Yes”, do you have coverage in the amount of $1,000,000 for each occurrence and $2,000,000 in the
aggregate as well as an umbrella policy of $3,000,000 for each occurrence and $3,000,000 in the
aggregate?
 Yes
 No
CLINIC OPERATION
If clinic location is currently registered, please go online to myfloridalicense.com or use VM 5 to
update dates and times
Date
Start Time
End Time
Section III – Affirmation by Written Declaration
AFFIRMATION BY WRITTEN DECLARATION
I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I
understand that my signature on this written declaration has the same legal effect as an oath or
affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts
stated in it are true. I understand that falsification of any material information on this application
may result in criminal penalty or administrative action, including a fine, suspension or revocation
of the license.
Signature:
Date:
Print Name:
DBPR VM 4
Eff. Date April 2013
Incorporated by Rule: 61-35.025
4 of 4
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1) Requirements for a Limited-Service Veterinary Medical Practice Clinic
a) All limited-service veterinary medical practice clinics must have a licensed veterinarian that will be
responsible for the management of the clinic.
b) Each limited service clinic must be registered with the Florida Department of Business and
Professional Regulation by name, address, date of clinic, time and duration at least 28 days
prior to offering the clinic.
c) The registration is valid through May 31 of each year, regardless of when the clinic was
operational.
d) For more information regarding the minimum standards for limited-service veterinary medical
practice please refer to
Chapter 61G18-15 of the Florida Administrative Code.
2) Application Instructions by section
a) Section I- Permit Holder Information
i)
Provide the name of the limited-service veterinary medical practice permit holder.
ii) Provide the limited-service veterinary medical practice permit number.
b) Section II- Clinic Information
i)
Fill out each section completely.
ii) Provide the name and address of the location where the clinic will be operating.
iii) Provide the dates and hours of operation for the clinic.
c) Section III – Affirmation by Written Declaration
i)
The applicant must sign the affirmation by written declaration.
DBPR VM 4
Eff. Date April 2013
Incorporated by Rule: 61-35.025