Health Certificate Questionnaire

Health Certificate Questionnaire
Owner Information:
Owner Name:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Alternative Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Physical Address in Hawaii:*

Street Address

Street Address Line 2

CityState

Zip Code
Physical Address in new destination state:*

Street Address

Street Address Line 2

CityState

Zip Code
What is the reason for travel?*
Departure Date:*

MonthDayYear
Date
Airlines:*
Is your Pet traveling in CARGO or CABIN?*
Pet Information:
Pet’s Name:*
Dog / Cat*
DOB:*
Sex:*
Breed:*
Color/ Markings:*
Microchip#: *
Is your pet up-to-date on Rabies Vaccine?*

YesNo
If yes, please list the name of the clinic and phone number of where vaccine was given.*
If no, would you like us to reach out and schedule an appointment to check out our Wellness Package that includes the Rabies vaccine?

YesNo
Should be Empty: