Health Certificate Pre-Appointment Form

Please fill out the below information to the best of your ability. This form must be completed prior to your international health certificate/consult appointment.

Owner Name*

First NameLast Name

Owner Phone Number*

Please enter a valid phone number.

Owner Email*

example@example.com

List the destination country you are traveling to with your pet.*

How many pets are traveling?*

Name of Previous Clinic*

Phone Number of Previous Clinic*

Pet Name #1*

Pet's birthdate or current age:*

How old will the pet be at the date of travel?*

What species of pet will be traveling?*

What breed of pet will be traveling?*

Sex of Pet*

MaleFemale

Is your pet spayed or neutered?*

YesNoUnknown

Does your pet have a microchip?*

Yes (list implant date below)Yes, I don't know when it was implanted but I will find outNo

Date microchip implanted on:*

Who administered your pet's last Rabies vaccine?*

A veterinarian at North Austin Animal Hospital administered my pet's Rabies vaccineA veterinarian outside of North Austin Animal Hospital administered my pet's last rabies vaccination. I will need to bring the last valid signed rabies certificate with microchip number to my appointment.I don't know.My pet isn't vaccinated for rabies.

Date last rabies vaccine given:*

Pet Name #2

Pet's Birthdate or Current Age?

How old will the pet be at the date of travel?

What species of pet will be traveling?

What breed of pet will be traveling?

Sex of Pet

MaleFemale

Is your pet spayed or neutered?

YesNoUnknown

Does your pet have a microchip?

Yes (list implant date below)Yes, I don't know when it was implanted but I will find outNo

Date microchip implanted on:

Who administered your pet's last Rabies vaccine?

A veterinarian at North Austin Animal Hospital administered my pet's Rabies vaccineA veterinarian outside of North Austin Animal Hospital administered my pet's last rabies vaccination. I will need to bring the last valid signed rabies certificate with microchip number to my appointment.I don't know.My pet isn't vaccinated for rabies.

Date last rabies vaccine given:

I understand that if the last rabies vaccine was not done at North Austin Animal Hospital, I must bring a copy of the signed Rabies certificate with microchip number to my appointment.

Who is accompanying your pet while traveling?*

The OwnerA person authorized by the ownerNo oneA pet transport company

How is your pet leaving the United States (air, car, boat etc.)? *

Will your pet be traveling in cabin or cargo?*

What date is your pet(s) leaving the United States (last air or seaport in the US)?*

Provide the date YOU arrive in the destination country?*

Provide the date YOUR PET(s) arrives in the destination country?*

List the address(s) and phone number(s) of your current location and the country where your pet will stay during the visit.

Ship from (name)*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Country*

Telephone*

Airport*

Ship to (name)*

Address*

Street Address

Street Address Line 2

CityState / Province/Canton/Sector

Postal / Zip Code

Country*

Telephone: *

Airport*

Airline*

List any countries your pet will land in before the destination country is reached.*

Does your destination country require an import permit?*

YesNoI don't know but will find out before I travel.

Did your airline or cruise ship give you any additional travel requirements for your pet?*

Yes, I will give to the veterinarian issuing my international health certificate.No

I have received, understand and signed the disclaimer form.*

YesNo, I understand this needs to be done before the Health Certificate.

Signature