International Health Certificate

International Health Certificate
Client Information
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Address In USA

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address In Foreign Country

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet Information
Pet's Name
Type of Pet

DogCatBirdRabbitOther
Breed
Date of birth
Month Day, Year
Gender

Male IntactMale NeuteredFemale IntactFemale Spayed
Microchip Number
Date of Microchip Implantation
Site of Implantation
Means of Transport
Identifying Characteristics of Transport
Border Crossing Point/ Port of Embarkation
The USDA typically will not look at a health certificate form until 72 hours of departure or arrival. Please sign below to acknowledge
Signature

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Client Information