International Health Certificate Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.INTERNATIONAL HEALTH CERTIFICATE WORKSHEETComplete this worksheet and submit prior to scheduling a consultation with our USDA Accredited Veterinarian. All information must be fully filled out with documentation of vaccinations in order to proceed with a consultation. I acknowledge that I have read and understand the provisions, requirements and information presented above regarding this Health Certificate Worksheet Above. *YesOwner Information *FirstLastPlease Enter Your NameCurrent Address *Phone Number *Email *TRAVEL INFORMATIONWhat Country Is Your Pet Traveling To? *List The Address(s) And Phone Number(s) In The Destination Country Where Your Pet Will Stay During This Visit: *What Airline Will Your Pet Be On For The Travel? *Will The Plane Stop For Layovers? Please List Any Stops Or Plane Changes That Will Occur: *If there are no layovers or plane changes please enter “None”Who Is accompanying Your Pet While Traveling? *The OwnerPerson Authorized By OwnerPet Transport CompanyNo OneHow Is Your Pet Leaving The United States?Air (Direct Flight)Air (Layovers In Another Country)CarTrainBoat/Ship (Direct)Cruise ShipWhat Date Is Your Pet Leaving The United States *How Many Pets Are Traveling? *How Old Will The Pet Be At The Date Of Travel? *Enter Pet’s AgeDid Your Airline Or Cruise Ship Give Any Additional Travel Requirements For Your Pet? If So, Please List Them Below. *If there are no additional requirements, please enter “None”PET INFORMATIONPet's Name *Sex Of Pet *MaleFemaleSpayed Or Neutered? *YesNoColor? *Does Your Pet Have A Microchip? *YesNo United Your and Microchip Number: *If Your Pet Does Not Have A Microchip Please Enter “None”VACCINATION INFORMATIONPlease Provide You’re Pet’s Vaccination Information Below.What Veterinary Clinic Performed Your Pets Vaccines? *Month And Year Of Vaccinations *If you’re not sure, give the approximate month and year in a mm/yy format.Is Your Pet Current On A Rabies Vaccine? *YesNoWho Administered The Pet's Last Rabies Vaccine? *Which Heartworm Prevention Does Your Pet Take?Date Given? *If you’re not sure, give the approximate month and year in a mm/yy format.Is Your Pet On Flea And Tick Prevention? *YesNoDate Given? *If you’re not sure, give the approximate month and year in a mm/yy format.Owners Signature *By selecting the “Submit” button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “Submit” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. I may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting the signature requestor directly, which may delay transactions. I may contact the signature requestor separately to request to sign this document on paper or to receive a paper copy of the signed document. Any fees for such paper copy will be charged then by the signature requestor. When I sign the document, I will receive a copy of this document via email. Submit
