Are you an existing client of Brooklyn Heights Veterinary Hospital?
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Yes
No
Please provide an email address we can use to contact you with follow-up information
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example@example.com
If you do not have an email address, please provide a phone number we can use to contact you with follow-up information
Please enter a valid phone number.
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Domestic Contact Information
Please provide the name and contact information of the CONSIGNOR (pet owner, or person designated to care for the pet, in the USA)
Consignor Name
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First Name
Last Name
Consignor Address
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Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Consignor Phone Number
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Please enter a valid phone number.
Some documents may need to be shipped from the USDA back to the owner. How would you prefer to receive the documents?
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Ship directly to the domestic address provided above
Ship to BHVH, I will pick it up there
Ship to a different address
International Contact Information
Please provide the name and contact information of the CONSIGNEE (pet owner, or person designated to care for the pet, in the DESTINATION COUNTRY)
Please choose one of the following regarding your international contact information
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I have this information now
I do not have this information yet but understand that I must provide it to Brooklyn Heights Veterinary Hospital in a timely manner, prior to my pet's examination
Consignee Name
First Name
Last Name
Consignee Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Consignee Phone Number
-
Country Code
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Area Code
Phone Number
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Travel Details
Pet details will be in the following section!
What country/countries is the pet traveling to?
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What type of trip is the pet embarking on?
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Temporary travel (eg. Accompanying owner on vacation. The pet will return to the US)
Permanent (eg. The owner is moving abroad, or the pet is being rehomed abroad)
Transit (The pet is exiting customs in a country while en route to the destination country)
Re-entry (The pet did not originate in the USA and is returning to the owner's home country)
Other
Please choose the option that best describes the pet's travel
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The owner is traveling on the same plane as the pet
A designated person (someone authorized by the owner) is traveling on the same plane as the pet
The pet is traveling under the sole responsibility of a Pet Transport Company or Airline Cargo, AND the owner (or designated person) will travel within 5 days prior to, or after, the pet travels
Neither the owner nor a designated person is traveling within 5 days of the pet
I don't know yet
Other
Departure Date
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Month
-
Day
Year
What airport will your pet arrive at?
Return Date (if not a permanent move)
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Month
-
Day
Year
Are there any further travel details you would like to provide?
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Pet Details
Please only include information about the pet(s) that will be traveling at this time.
Pet Information
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Does your pet take parasite prevention?
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My pet takes ONLY flea and tick prevention and is up to date.
My pet takes ONLY heartworm prevention and is up to date.
My pet takes BOTH flea and tick and heartworm prevention, and is up to date.
My pet has taken parasite preventatives in the past, but is not up to date.
My pet has never taken parasite preventatives.
Other
If you have medical records for your pet(s) that we might need, please attach them here.
Browse Files
Drag and drop files here
Choose a file
If you are a new client, this would be full medical records. If you are an existing client but your pet got its rabies vaccine or other relevant vaccines or testing completed at another vet, please upload those records here.
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If you do not have medical records but think we may need them, please give us the contact information of any veterinarian your pet has visited in the last 3 years.
Is there any further information you would like to provide about your pet(s)?
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Further Information and Terms Agreement
Name of Person Submitting Form
First Name
Last Name
Signature
*
Submit
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