Health Certificate CVI Request Form
This form is designed to help us at Cottonwood Animal Clinic prepare Certificates of Veterinary Inspection (CVI) or health certificates for dogs and cats.
Consignor Information
The person who owns the pet.
Consignor Name
*
First Name
Last Name
Consignor Email
*
example@example.com
Consignor Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Consignor Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Consignee Information
The person receiving the pet. If there is no change of ownership, then fill in the same information as the consignor. For example, if this is a CVI for a pet going to a show or exhibition, please add in the name of the of the show in the notes section, but add in contact and location information in this section.
Consignee Name
*
First Name
Last Name
Consignee Email
example@example.com
Consignee Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Consignee Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Notes
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Pet Movement Details
Starting date of travel
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Method of travel
*
Please Select
Air Cabin
Air Cargo
Automobile
Truck/Trailer
Rail
Water
Purpose of movement
Adoption
Breeding
Exhibition / Show
Medical Treatment
Owner relocating
Personal travel
Research
Sale
Training
If traveling by air, please be sure to list the airline and city of departure
Carrier
Consignor (owner)
Consignee (recipient)
Other
Carrier Information
Carrier Contact (3rd party transport service)
First Name
Last Name
Carrier Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Carrier Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Pet Information
Name
*
Species
Canine (dog)
Feline (cat)
Avian (bird)
Breed
*
Do you know date of birth?
yes
no
Known date of birth
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Estimated date of birth
Estimated date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Female
Female, spayed
Male
Male, neutered
Color
*
Identification, please list additional ID such as microchip, breed registration papers, Rabies tag number or collar color
Submit
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