Pet Health Certificate Consult Request
Bellevue Animal Hospital, PC
Pet Name
*
Image
Browse Files
Drag and drop files here
Choose a file
Please upload a clear and well-lit photo of your pet for our records
Cancel
of
Species
*
Please Select
Dog
Cat
Rabbit
Bird
Reptile
Other
Breed
*
Sex
*
Female
Male
Female Spayed
Male Neutered
Pet's Date of Birth
*
-
Month
-
Day
Year
Please use exact date if known, otherwise an estimate.
Pet's Color
*
Microchip Number
*
Number must be 15 digits to be valid for international travel!
Microchip implant date
-
Month
-
Day
Year
Date
Owner Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
May we text you at that phone number?
*
Yes
No
Email
*
example@example.com
Current address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your travel destination?
*
Is this a permanent move, long term deployment, or a vacation?
*
What date is your pet departing from Omaha? (Please enter the earliest estimated date if your plans are not yet finalized.)
*
-
Month
-
Day
Year
Date
What date is your pet arriving in the destination country? (Please enter the earliest estimated date if your plans are not yet finalized.)
*
-
Month
-
Day
Year
Date
If traveling for a vacation, when will your pet return to the United States? (Please enter the earliest estimated date if your plans are not yet finalized.)
-
Month
-
Day
Year
Date
What is the planned flight itinerary? Please provide flight dates and include details of any additional countries that you will visit with your pet. Include details of any additional countries that your pet will "transit" prior to the pet reaching the final destination; this includes plane changes and layovers.
*
What airline will your pet be traveling with?
*
Will you and your pet be on the same flight?
*
Yes
No
If you and your pet will not be on the same flight, please provide YOUR travel details: departure date from USA and arrival date in destination country.
Will your pet be flying in the airplane cabin or in the cargo hold?
*
Cabin
Cargo
Will you be using a pet transport assistance service? If yes, please provide the name of the company and your representative's contact information.
*
What is the address of your new home or vacation residence in the destination country? Please note that we must have a physical address (street address) for your health certificate. Military APO addresses or PO Box addresses are NOT accepted on health certificates
*
Date of your pet's most recent rabies vaccination?
*
-
Month
-
Day
Year
Date
Please upload a clear copy of your pet's most recent rabies vaccination certificate.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date of your pet's prior rabies vaccination? (The vaccination prior to the most recent one.)
*
-
Month
-
Day
Year
Date
Please provide the clinic name and contact information for your pet's current regular veterinarian. We may need to contact that veterinarian if additional medical records are required to facilitate your pet's health certificate and pre-travel requirements.
*
A non-refundable $50.00 health certificate consultation fee is required in order to review your pet's current medical records and determine what pre-travel vaccinations and/or tests have been completed or still need to be done. After submitting this form, please contact our office at 402-291-1255 to make payment via credit card. If you wish to pay by cash or check, visit our office at 10410 S. 25th Street, Bellevue, NE.
We accept American Express, CareCredit, Discover, MasterCard, and Visa.
Signature
*
Save
Submit
Should be Empty: