Health Certificate Preparation Form

Health Certificate Preparation Form
Owner Information
Owner #1 (Legal name as written on passport/ID)*

First NameLast NameSuffix
Owner #2 (Legal name as written on passport/ID)

First NameLast NameSuffix
Physical Address (Origin) - P.O. Box NOT ALLOWED*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Origin)*
Please enter a valid phone number.
Email*
example@example.com
Address (Destination) - P.O. Box NOT ALLOWED*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number (Destination)*
Please enter a valid phone number.
Date of Travel*

MonthDayYear
Date
Are you and your pet traveling on the same date?*

YesNo
If your pet is NOT traveling with you, what date is your pet traveling?

MonthDayYear
Date
Is someone else traveling with your pet? If someone is traveling with your pet, please fill out the next 4 questions.

NoYes
Pet Transporter Legal Name (as it appears on passport/ID)

First NameLast Name
Pet Transporter Address - P.O. Box NOT ALLOWED

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet Transporter Phone Number
Please enter a valid phone number.
Pet Transporter Email
example@example.com
Is your pet traveling cargo or in the cabin?

CargoCabin
How are you traveling?*

AirCar/TruckBoatOther
What airport or port are you departing from?
Are you making multiple stops before arriving to your destination?*

NoYes
If yes, what other countries are you traveling through?
Are you using/required to use a pet import coordinator? If yes, please fill out the next question with their information.*

YesNo
Pet Import Coordinator Name

First NameLast Name
Pet Import Coordinator Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet Import Coordinator Phone Number
Please enter a valid phone number.
Pet Import Coordinator Email
example@example.com
Are you returning to the United States?*

YesNo
What date are you planning on returning to the Untied States?

MonthDayYear
Date
Pet Information
What types of pets are you traveling with?*

DogCat
How many pets are you traveling with?*
Pet #1 Name*
Pet #1 Species*

DogCat
Pet #1 Breed*
Pet #1 Sex*

Female IntactFemale SpayedMale IntactMale Neutered
Pet #1 Date of Birth*

MonthDayYear
Date
Pet #1 Color*
Pet #1 Microchip Number*
Pet #1 Microchip Implant Date*
Pet #2 Name
Pet #2 Species

DogCat
Pet #2 Breed
Pet #2 Sex

Female IntactFemale SpayedMale IntactMale Neutered
Pet #2 Date of Birth

MonthDayYear
Date
Pet #2 Color
Pet #2 Microchip Number
Pet #2 Microchip Implant Date
Pet #3 Name
Pet #3 Species

DogCat
Pet #3 Breed
Pet #3 Sex

Female IntactFemale SpayedMale IntactMale Neutered
Pet #3 Date of Birth

MonthDayYear
Date
Pet #3 Color
Pet #3 Microchip Number
Pet #3 Microchip Implant Date
Have any of the above listed pets been seen by another hospital or vaccine clinic within the last 5 years?*

NoYes
If you answered yes above, please attach the records from all locations.

Cancelof
Health certificate requirements are vast and differ from country to country. The process to travel with your pet is complex and will take an extended period of time to complete all necessary paperwork. We will have one of our doctors review this form and call if we have further questions. We look forward to seeing you at your health certificate appointment!

Things to Bring to Your Appointment:
- Pet(s)
- Pet Passports (if applicable)
- Any paperwork regarding travel and pet health within the last 5 years.
- Previous health certificate (if applicable)
- Credit Card (This will be used to generate a FedEx Shipping label for your health certificate)
- Patience 🙂
Statements*

By submitting this form, I understand its submission does not guarantee eligibility of my pet(s) to travel and that regulations for travel are established by the destination countries and are beyond the control of Mother Lode Veterinary Hospital.
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Health Certificate Preparation Form

Owner Information

Pet Information