This form must be sent to the board directly from the recommending veterinarian



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THIS FORM MUST BE SENT TO THE BOARD DIRECTLY FROM THE RECOMMENDING VETERINARIAN




Department of Health Professions

Commonwealth of Virginia

Board of Veterinary Medicine


9960 Mayland Drive, Suite 300

Richmond, Virginia 23233-1463 (804)-367-4468



Recommendation for Registration as an Equine Dental Technician

Regulations of the Board of Veterinary Medicine require that a person applying for registration as an equine dental technician must provide a recommendation from at least two veterinarians licensed in Virginia who attest that at least 50 percent of their practice is equine; and that they have observed the applicant and can attest to his competency to be registered.

Name of Applicant for Registration____________________________________________

1. Please provide a summary of your observation of this applicant performing tasks relating to the practice of equine dentistry. Include the types of tasks you have observed the applicant performing (i.e., planing and leveling of equine teeth using nonmotorized tools; planing or leveling using motorized tools, or the extraction of wolf teeth premolars) and approximately how often you have observed the applicant and over what period of time. Respond on a separate sheet and attach to this form.


2. Please evaluate the applicant: (Please indicate with check mark)






Poor

Fair

Good

Superior

Professional knowledge
















Skill level
















Ethical/professional conduct
















3. Recommendation: (please indicate with check mark)



  • Recommend highly and without reservation ;

  • Recommend as qualified and competent 

  • Recommend with some reservation (explain) ______________________________________________________________________



I attest that at least 50 percent of my veterinary practice is equine and that the statements made in this recommendation are true to the best of my knowledge.


Date: _______________________________ Signed by: ______________________________________________

Print or type name: _______________________________________



Virginia veterinary license number: ________________________________________________________
(This report will become a part of the applicant’s file and may be reviewed by the applicant upon request.)

Effective 11/07


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