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? *

Month Day Year
Date Hour Minutes AM/PM Option
What is your travel date? *

Month Day Year
Date
Patient is traveling via:

Air Car Other
If traveling by air, select all applicable options:

International Domestic Cabin Cargo
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 Name Last Name
Email
email@example.com
Phone Number

Area Code Phone Number
Consignor Full Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Departure Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Consignee Full Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Destination Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient *

First Name Last Name
Date of Birth

Month Day Year
Date
*

Age Breed
Species *
Gender *

Immunization Data:

Microchip #
Select applicable travel requirements:

FAVN Rabies Antibody Test Airline Acclimation Certificate Minimum waiting period after Rabies vaccination USDA Accredited Veterinary Signature USDA 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. Cancel of
Should be Empty:

Point of Contact Information