Patient Intake Form

Travel Health Certificate Submission Form

This form is for current clients to submit information required prior to their appointment where the doctor will issue a health certificate required for travel.

Schedule an appointment PRIOR to filling out this form.
What is your current appointment day and time? *

MonthDayYear
DateHourMinutesAM/PM Option
What is your travel date? *

MonthDayYear
Date
Patient is traveling via:

AirCarOther
If traveling by air, select all applicable options:

InternationalDomesticCabinCargo
Airline Name(s)

1)2)
It is your responsibility to research airline & APHIS pet travel requirements PRIOR to arriving at your appointment. Print or email any required forms PRIOR to your appointment. Don't hesitate to contact the clinic, PRIOR to your appointment, with any questions or concerns about requirements.
Point of Contact Information
Name

First NameLast Name
Email
email@example.com
Phone Number

Area CodePhone Number
Consignor Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Departure Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consignee Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Destination Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient*

First NameLast Name
Date of Birth

MonthDayYear
Date
AgeBreed
Species*
Gender*

Immunization Data:

Microchip #
Select applicable travel requirements:

FAVN Rabies Antibody TestAirline Acclimation CertificateMinimum waiting period after Rabies vaccinationUSDA Accredited Veterinary SignatureUSDA APHIS Veterinary Medical Officer Signature
Please provide any additional information or concerns:
Attach Patient Records

Browse Files
Please attach copies of any medical records, rabies certificates, etc. Cancelof
Should be Empty:

Point of Contact Information