<h1>Health Certificate Form

Health Certificate Form

Please fill out this form, attach all files requested and email to hello@mercerislandanimalhospital.com
Name*

First NameLast Name
Date

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet Name*
Is your pet spayed or neutered?

YesNo
Pet Birth Date

MonthDayYear
Pet Gender
Pet Breed
Is your pet microchipped?

YesNo
When was the microchip administered?
Microchip #
Is your pet up to date on vaccinations?

YesNo
Do you have a copy of your pets rabies certificate?

YesNoN/A
Date of last rabies vaccination given?
Who can we contact for previous veterinary records?
Where are you traveling to?
Exact destination street address and phone number.
When do you plan to travel?
Will you be using a third party for travel planning?

YesNo
Name of travel company if applicable?
Have you traveled to current or other destination with pet before and where?
What is your pets stress level when traveling?

1

2

3

4

5

1 is Lowest, 5 is Highest
Thank You! Please send pets rabies certifiacte, microchip information and any previous veterinary records to hello@mercerislandanimalhospital.com prior to your scheudled appointment.
Should be Empty: