Form DBPR VM3 "Application for a Limited-Service Veterinary Medical Practice Permit" - Florida

What Is Form DBPR VM3?

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 VM3 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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Download Form DBPR VM3 "Application for a Limited-Service Veterinary Medical Practice Permit" - Florida

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State of Florida
Department of Business and Professional Regulation
Board of Veterinary Medicine
Application for a Limited-Service Veterinary Medical Practice Permit
Form # DBPR VM 3
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION REQUIREMENTS
ALL License Applicants must submit:
 Complete this application.
 Fees:
• $250 for Limited-Service Medical Practice Permit
• Make check payable to the Florida Department of Business and Professional Regulation.
 Read Rule 61G18-15.007, Florida Administrative Code, which outlines the minimum standards for a
limited service practice.
 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. To register clinics for limited service veterinary medical practice you must submit Form
# DBPR VM 4- Limited-Service Veterinary Medical Practice Clinic Registration which can be found at
www.myfloridalicense.com.
 If the owner of the establishment is not a Florida-licensed veterinarian, the owner will have their name
submitted by the department for a statewide criminal records correspondence check through the Florida
Department of Law Enforcement.
 Supporting legal documentation, if necessary. See Section IV of Instructions.
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.
DBPR VM 3
Eff. Date April 2013
Incorporated by Rule: 61-35.025
1 of 6
State of Florida
Department of Business and Professional Regulation
Board of Veterinary Medicine
Application for a Limited-Service Veterinary Medical Practice Permit
Form # DBPR VM 3
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION REQUIREMENTS
ALL License Applicants must submit:
 Complete this application.
 Fees:
• $250 for Limited-Service Medical Practice Permit
• Make check payable to the Florida Department of Business and Professional Regulation.
 Read Rule 61G18-15.007, Florida Administrative Code, which outlines the minimum standards for a
limited service practice.
 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. To register clinics for limited service veterinary medical practice you must submit Form
# DBPR VM 4- Limited-Service Veterinary Medical Practice Clinic Registration which can be found at
www.myfloridalicense.com.
 If the owner of the establishment is not a Florida-licensed veterinarian, the owner will have their name
submitted by the department for a statewide criminal records correspondence check through the Florida
Department of Law Enforcement.
 Supporting legal documentation, if necessary. See Section IV of Instructions.
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.
DBPR VM 3
Eff. Date April 2013
Incorporated by Rule: 61-35.025
2 of 6
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.
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.
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 3
Eff. Date April 2013
Incorporated by Rule: 61-35.025
3 of 6
State of Florida
Department of Business and Professional Regulation
Board of Veterinary Medicine
Application for a Limited-Service Veterinary Medical Practice Permit
Form # DBPR VM 3
[2603/1030]
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.
Section I – Permit Ownership (Applicant) Information
PERMIT OWNERSHIP INFORMATION
Name
Date of Birth (MM/DD/YYYY)
Social Security Number*
/
/
Gender
Race (Optional)
 Male
 Female
Street Address
City
State
Zip Code (+4 optional)
Do you hold a current and active license to practice Veterinary Medicine?  YES
 NO
If “YES”, provide license number:
______________________________
NOTE: In accordance with Section 474.215(8), Florida Statutes, any person who is not a veterinarian licensed under this chapter,
but who desires to own and operate a veterinary medical establishment, will have their name submitted by the department for a
statewide criminal records correspondence check through the Department of Law Enforcement.
* The disclosure of your Social Security number is mandatory on all professional and occupational license applications, is solicited
by the authority granted by 42 U.S.C. §§ 653 and 654, and will be used by the Department of Business and Professional Regulation
pursuant to §§ 409.2577, 409.2598, 455.203(9), and 559.79(3), Florida Statutes, for the efficient screening of applicants and
licensees by a Title IV-D child support agency to assure compliance with child support obligations. It is also required by § 559.79(1),
Florida Statutes, for determining eligibility for licensure and mandated by the authority granted by 42 U.S.C. § 405(c)(2)(C)(i), to be
used by the Department of Business and Professional Regulation to identify licensees for tax administration purposes.
Section II – Permit Information
PERMIT INFORMATION
Tax Identification Number:
Permit Name:
Doing Business As (D/B/A):
CLINIC MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
CONTACT INFORMATION
Telephone Number
Fax Number
Email Address
RESPONSIBLE VETERINARIAN
Name:
License Number:
DBPR VM 3
Eff. Date April 2013
Incorporated by Rule: 61-35.025
4 of 6
Section III – Minimum Standards for Limited-Service Veterinary Medical Practices
MINIMUM STANDARDS FOR LIMITED-SERVICE VETERINARY MEDICAL PRACTICES
Does the veterinary premise meet all of the applicable minimum standards for limited-
 YES
service veterinary medical practice requirements established in Chapter 61G18-15 of
 NO
the Florida Administrative Code?
Section IV(a) – Background Question
BACKGROUND QUESTIONS
If you answer “YES” to the question below, please refer to Section IV of Instructions for detailed
instructions on providing a complete explanation, including requirements for submitting supporting legal
documents. Please complete Section IV (b) if you respond “YES” to question 1. If you have more
offenses/incidents to document in Section IV (b), attach additional copies as necessary.
Have you ever been convicted or found guilty of, or entered a plea of nolo
contendere or guilty to, regardless of adjudication, a crime in any jurisdiction,
or are you currently under criminal investigation? This question applies to any
criminal violation of the laws of any municipality, county, state or nation,
including felony, misdemeanor and traffic offenses (but not parking, speeding,
inspection, or traffic signal violations), without regard to whether you were
placed on probation, had adjudication withheld, were paroled, or pardoned. If
you intend to answer “NO” because you believe those records have been
1.
expunged or sealed by court order pursuant to Section 943.0585 or 943.059,
Yes
No
Florida Statutes, or applicable law of another state, you are responsible for
verifying the expungement or sealing prior to answering "NO." YOUR
ANSWER TO THIS QUESTION MAY BE CHECKED AGAINST LOCAL,
STATE AND FEDERAL RECORDS. FAILURE TO ANSWER THIS
QUESTION ACCURATELY MAY RESULT IN THE DENIAL OR
REVOCATION OF YOUR LICENSE. IF YOU DO NOT FULLY
UNDERSTAND THIS QUESTION, CONSULT WITH AN ATTORNEY OR
CONTACT THE DEPARTMENT.
Section IV (b) – Explanation(s) for Background Question 1
EXPLANATION
Offense
County
State
Penalty/Disposition
Date of Offense (MM/DD/YYYY)
Have all sanctions been satisfied?
/
/
 Yes  No
Description
DBPR VM 3
Eff. Date April 2013
Incorporated by Rule: 61-35.025
5 of 6
Section V – 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 3
Eff. Date April 2013
Incorporated by Rule: 61-35.025