Travel Health Certificate Questionnaire

NEFFSVILLE
International Travel Health Certificate Questionnaire
Thank you for choosing Neffsville Veterinary Clinic for your pet's travel needs. Please ensure that the information you fill out on this form is accurate. We will use this information to fill out the necessary paperwork for your pet. If you have any questions before your visit, please don't hesitate to contact us. Please know that some countries require 6-12 months of planning. We require a $105 non-refundable deposit at the time of travel document review.

**Neffsville Veterinary Clinic will not be responsible for any inaccurate information provided by the client.**
Pets Name*
Breed*
Pets Date of Birth*

MonthDayYear
Date
Sex*
Is your pet spayed or neutered?*

YesNo
Species*
Weight*
Color*
CLIENT'S INFORMATION:
Client Name (First and Last)
Phone Number*
Address*

Address

Street Address Line 2

CityState & Zip

Postal / Zip Code
Email*
example@example.com
Are you currently a client at NVC?*
If no, please provide contact information for your current veterinary provider
We can not schedule a travel appointment until we have your pets complete up to date records.
Address of Final Destination*
City*
State
Country
Destination Phone Number

Country CodeArea CodePhone Number
US Port of Departure
Date of Departure from US

MonthDayYear
Date
Date of Arrival at Final Destination*

MonthDayYear
Date
Airport/Port of Entry back into US
Date of Entry back into US

MonthDayYear
Date
Will you be stopping anywhere other than the final destination?
Additional dates of travel

MonthDayYear
Date
Additional travel addresses
Will you be traveling with your pet?*

YesNo, my pet will be departing at another time
How will your pet be traveling?*

Flying in CabinFlying in CargoIn CarOther
If other, please specify details
Will your pet be traveling with someone other than yourself?*

NoYes (provide details below)
If other, please specify details
Rabies vaccine information is found on pet's rabies certificate; if you do not have that document, you will need to contact your previous veterinary clinic for records. *Please bring rabies certificates to your appointment*
Where was the most recent rabies vaccination done?*
Date of Most Recent Rabies Vaccination*

MonthDayYear
Date
Manufacturer*
Serial Number*
Duration*
Expiration Date*

MonthDayYear
Date
*If a rabies titer test is required for your country of destination, we will need to schedule a separate appointment for this test. The timing depends on your destination. *

Depending on the destination, we may need the earliest date your pet's microchip was scanned and documented; if the date of microchip placement is unknown, you may need to contact your previous veterinary clinic for records. You will also need to verify if it is ISO compliant (15 digit code). This information can be found on the USDA APHIS Pet Travel website.
Where did your pet get their microchip if not here?
Microchip Number*
Date of Microchip Placement*

MonthDayYear
Date
You must visit the USDA APHIS website (http://www.aphis.usda.gov/aphis/pet-travel) to make sure your pet meets all the requirements for entry at your destination.

There are new CDC requirements for high risk rabies countries. There are certain countries that require additional paperwork. This additional paperwork may need to be submitted electronically. With the exception of certain countries, international health certificates must be endorsed by the USDA after we issue it. This can be done by mailing a hard copy to the USDA or electronic filing.

You must mail the health certificate to the office for endorsement or electronic filing. If you chose to mail the health certificate, we recommend mailing overnight. Include a self-addressed, prepaid overnight envelope so that the USDA can overnight documents back to you.
If you have additional questions, you may contact the USDA APHIS office:

USDA North Carolina APHIS Endorsement Office

920 Main Campus Dr. Suite 200 Raleigh, NC 27606

Phone Number: (919) 855-7111 Email: vspspa@usda.gov

IMPORTANT DOCUMENT SUBMISSION AND ENDORSEMENT INFORMATION:

Include the following items when mailing/coming in for endorsement:

1. ORIGINAL health certificate or document. The health certificate MUST be completed, signed and dated by a USDA accredited veterinarian.

2. Rabies vaccination certificate

3. Import permit and test results (if required by importing country)

4. Payment for endorsement services *Payment types accepted: User Fee Account, Check, Money Order, Credit/Debit Card *More information about User Fees - Charges for Health Certificate Endorsement

5. Prepaid, pre-addressed return shipping label (FedEx, UPS, USPS)

*The "TO" and "FROM" name/address should be your own. Return shipping labels that contain a USDA address may be rejected.

*Not required for documents submitted for endorsement in-person.
THIS OFFICE DOES NOT REVIEW DOCUMENTS PRIOR TO SUBMISSION FOR ENDORSEMENT
To ensure you get your documents back in time for your trip, please schedule your appointment with us within the time frame of the destination. It may take our office 48 hours to complete the certificate.

Hawaii Travel: Please visit the Hawaii Department of Agriculture's website to ensure your pet meets all the requirements https://hdoa.hawaii.gov/ai/

Airlines: Please be aware that the airlines have their own requirements for travel so in addition to making a reservation for your pet, you will need to make sure that you have all of the necessary documents.

Signature: I acknowledge that I have read through this form in its entirety and have visited the USDA APHIS website to make sure my pet meets all the requirements for entry at my destination.
Clients Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

NEFFSVILLE

International Travel Health Certificate Questionnaire

CLIENT'S INFORMATION:

THIS OFFICE DOES NOT REVIEW DOCUMENTS PRIOR TO SUBMISSION FOR ENDORSEMENT