BTCA Health Examination Form
The following Exam is to be completed by your regular Veterinarian in conjunction with a physical exam.
AKC Registered Name of Dog: ___________________________________________________________
Date of Birth: ______________________________________ Dog must be 1 year of age minimum.
AKC Registration #: ________________________________ Color: ____________________________
Permanent ID #:____________________________________ (Circle one: Microchip, Tattoo or DNA)
Owners Name: ________________________________________________________________________
Address: _____________________________________________________________________________
City: ______________________________________ State: __________________ Zip: _____________
HEALTH EXAM TO BE PERFORMED BY YOUR VETERINARIAN:
Patella’s: Examination showed sound Patella’s and the OFA Certification Application forms have been completed
according to OFA instructions given to owner.
Airway Patency: (Failure could be exhibition of cyanosis or distress due to stress of the examination, history of
fainting or inability to tolerate heat or humidity, stenotic nares causing mouth breathing, excessive congestion in
the throat indicative of elongated palate, history of exercise intolerance. Previous corrective surgery for enlarging
nares or shortening palate): _____PASS _____FAIL
GENERAL HEALTH: Please check if known to exist:
_____ Deafness in 1 or both ears _____ Open Fontanel
_____ Addison’s Disease _____ Cushing’s Disease
_____ Hypothyroidism _____ Cancer
_____ Inverted Tail _____ Heart Defect
_____ Hip Dysplasia _____ Inguinal Hernia
_____ Cardiomyopathy _____ Symptoms of distress indicating Hemivertebra
Any item checked above will be considered a failure of this exam. _____ PASS _____ FAIL
Please check: PASS or FAIL on each item below:
REPRODUCTIVE: An undescended testicle for a male would constitute a failure: _____ PASS _____ FAIL
SEIZURE HISTORY: All seizures not known to be caused by trauma, anesthesia or other drugs would constitute a
failure. _____ PASS _____ FAIL
DEMODEX HISTORY: Localized Demodex not requiring Treatment is acceptable. Generalized Demodex
requiring medical treatment would constitute failure. _____ PASS _____ FAIL
ALLERGIES: Allergies which cause severe distress or require continuous treatment. _____ PASS _____ FAIL
I, ____________________________________, certify that I have examined this dog on (Date) _____________
And believe him/her to be basically sound and free of disease of probable hereditary origin. I believe this dog is a
good candidate for breeding. Name of Veterinarian ______________________________________________
State License # _________________________ Name of Clinic: ______________________________________
Address: ________________________________________________________State:
_____________________ ZIP: ____________________________ Phone #: ___________________________
By submitting this application I state that I am a member in good standing with the Boston Terrier Club of America
and comply with the BTCA Code Of Ethics. And that this dog complies with the current AKC Breed Standard for
Boston Terriers. SIGNATURE: ________________________________________________
"This form supercedes any other form, rule or regulation previously posted. Each Certificate is good for one year
from the date of issue."
Revised 7/10/06 (Page 1)
BTCA Health Examination Form Instructions:
Documentation to be sent along with this application:
Silver Certification: To receive your Silver Health Certificate you must submit for each dog:
1.) The original completed Health Examination Form signed by your Veterinarian.
2.) A photo copy of the CERF Certificate showing number and CERF Date issued.
3.) A photo copy of the OFA Patella Certificate showing number and date issued.
Gold Certification: In addition to the items needed for the Silver Certificate please send a photo copy of the
OFA BAER Certificate.
Reference Information:
The BAER test only needs to be performed once in a dog’s life sometime after he or she is 35 days of age.
CERF recommends having their exam performed annually with the first test being performed anytime after the
puppy is 8 weeks of age. Your dog must be permanently identified by Microchip, Tattoo or DNA prior to this test
to have the results recorded.
Patella Examination can be preformed on any dog that has reached 1 year of age and results can be recorded
with OFA at that time. Exams performed before one year of age will be treated as a Consultation and no number
will be issued by OFA. OFA recommends having this exam performed bi-annually.
To apply for your BTCA Health Certificate Award please complete the preceding application (Page 1) and attach
the appropriate documentation to it for the level of Certificate you are applying for. Please mail it to me prior to
the deadline of January 31, 2007 with your check or money order of $5.00 made payable to the
“BTCA Health Committee” and marked for “Certification”.
Sue LeCalsey
BTCA Health Committee
4125 Dollar Lane
DePere WI 54115
If you have any questions, please feel free to contact me for help at AchatesBostons@Ameritech.Net.
(Page 2)
Revised 7-10-06