Release Form for Owners Requesting Domestic and/or International Health Certificates

Information for Domestic and International Health Certificates

Please read the information below carefully so you are aware of any necessary requirements for you and your pet to complete prior to travel. Because our veterinarians are licensed and accredited in the State of Minnesota, only pets who reside in the State of Minnesota may be issued a Certificate of Veterinary Inspection
When travelling with your pet(s), there may be animal health requirements specific for that destination. As soon as you know your travel details, contact your local veterinarian to assist with the pet travel process. Factors to consider may include meeting time frames for obtaining a health certificate, updating vaccinations, diagnostic testing, or administration of medications/ treatments.

Your destination state or country may have specific health requirements that must be met before your pet can enter the state or country. Since export requirements are determined by each state or country and can change frequently, every time you plan pet travel you will need to verify the export requirements. Please note that airlines may have separate and additional requirements. Check with your airline to determine what requirements they may have, if any.

The process for taking a pet bird or other exotic animal out of the United States may involve multiple agencies including USDA APHIS Veterinary Services (VS), and U.S. Fish and Wildlife Service (FWS). It is critical that you meet ALL requirements for each of these agencies prior to export.

To learn the requirements for moving your pet from your current location to another U.S. state or foreign country, please review the links listed below. If you have additional questions or need to determine what type of form will be accepted when the pet travels, please contact the State Veterinarian’s office in the destination state or the United States Department of Agriculture.

USDA - Helpful Pet Travel References

USDA - Taking Your Pet to a Foreign Country (International Travel)

USDA - Taking Your Pet State to State (Interstate/Domestic Travel)

USDA - Bringing Your Pet Back to the United States
Information the United States Department of Agriculture REQUIRES to Complete a Interstate and/or International Certificate of Veterinary Inspection (CVI)

Please fill out the required fields below and make sure to attach any veterinary records and/or vaccine certificate(s) for services that were not provided by SHPH. We will be unable to schedule your appointment for travel or complete your pet's CVI without this information well in advance
Owner's Name*

First NameLast Name
Preferred Pronouns
Owner's Phone Number*
Please enter a valid phone number.
Owner's Email*
example@example.com
Owner's Date of Birth*

MonthDayYear
This is required for SHPH to have on file for prescribing and/or dispensing controlled substances
Owner's State Driver's License or Identification Card Number*
This is required for SHPH to have on file for prescribing and/or dispensing controlled substances
State Issued*
Owner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Co-Owner (if applicable)

First NameLast Name
Please tell us how the above person is related to you so we can refer to your relationship appropriately
Have you ever brought a pet to South Hyland Pet Hospital before?*

YesNo
Pet's Name*
Species (Dog, Cat, etc.)*
Pet's Sex*
Breed and Color*
Date of Birth/Age of Your Pet*
Please indicate age in either weeks, months or years
Microchip Number (If Known)*
If you do not know your pet's microchip number or are unsure if they have one, please write "Unknown" If your pet does not have a microchip, write "N/A" ***Please note that pets REQUIRE an ISO compliant microchip for international travel and vaccinations administered prior to microchip implantation are considered invalid***
For what purpose was your pet obtained?*

CompanionshipProtectionService AnimalBreedingCompetitive ShowingOther
Age of pet when obtained?*
Type of food(s) you feed your pet?*

DryMoistCannedOther
Brand of pet food you feed your pet?*
Daily feeding amount and frequency?*
Please list any treats you give your pet and how often you offer them
Do you have any nutritional questions for the veterinarian? If so, please elaborate in the space below
Current list of medication(s) and dosages
Known reaction to medication(s) or allergies?
Please describe and prior significant illness/injury or surgical procedure(s)
Date of pet's last dental cleaning?
Previous Veterinarian(s)*
Please include the name of the hospital and their phone number
Does your pet have a valid Pet Passport?*

YesNoNot Sure
If your pet has a valid Pet Passport, please state the country of origin
Please attach your pet's previous health records if they have received medical care from anywhere else besides South Hyland Pet Hospital

Cancelof
Primary reason for visit to South Hyland Pet Hospital?*
Please check any of the following symptoms that you have noticed lately:

Appetite changeLimpingSneezingScootingCoughingScratchingThirst/Urination ChangeVomitingDiarrheaShaking headWeaknessLethargyOther (list below)
Do you consider any of these symptoms a problem? If so, please elaborate
Does your pet currently have any behavior problems that you are concerned about?*

YesNo
If so, please describe these issues below
Additional services available with exam (multiple selections allowed)

Anal Gland ExpressionNail TrimMicrochip Placement
Do you need any food, treats or medication refills (including heartworm, flea and tick prevention) that you would like to pick up at your appointment?
Wen listing medication refill requests, please include the name of the drug, dose, current dosing instructions and quantity desired
Is there anything else about your pet(s) that you would like us to know about?
Upload a picture of your pet

Cancelof
Date of Travel*

MonthDayYear
Date
Method of Travel/Transportation*
Airplane, Cargo Ship, Train, Car, Trailer, Etc.
Name of Airline (Or other method of transportation)*
Ex. Delta Airlines
City, State and Country of Departure*
City, State and Country of Arrival*
Reason for Travel?*
Ex. Moving, vacation, etc.
Are you planning on returning to the United States?*

YesNoNot Sure
Date or Estimated Date of Return to the United States (If Applicable)

MonthDayYear
Please note that depending on your date of return, you may need to have a health certificate re-issued by a veterinarian from the country you are traveling from to enter the United States with your pet
Name of Recipient or Consignee (If different from Owner)

First NameLast Name
Phone Number (If different from Owner)
Please enter a valid phone number.
Email (If different from Owner)
example@example.com
Address of Destination*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Advance Veterinary Care Directive(s)
Advance directives are instructions provided by pet owners in advance, to guide veterinarians as to what, if any, life sustaining treatments should be provided to a pet in the event of a medical emergency.

These instructions are crucial, especially if an owner cannot be reached in a safe or timely manner.

For pets that have been admitted to the hospital for a surgical or medical procedure that may or may not require sedation or general anesthesia, an advance care directive must be on file.

It's understandable that discussing emergency resuscitation for pets can be a challenging topic, but it's an important conversation to have.

Knowing what emergency resuscitation entails and understanding the procedures involved, can help pet owners make informed decisions. CPS, including chest compressions and drug administration like epinephrine, along with manual ventilation, are vital components of resuscitation efforts. However, it's also important to recognize that despite best efforts, survival rate for pets experiencing cardiac or respiratory arrest are relatively low.

Each pet owner's decision regarding resuscitation is deeply personal and may depend on various factors, such as the pet's age, health status and the presence of terminal illness. Regardless of the decision, our staff is well-trained to handle emergency situations with care and professionalism.

Owners may elect at any point to change their decision.

We want to encourage pet owners to discuss their wishes and expectations regarding emergency care with their families and veterinarians beforehand. This proactive approach helps ensure that everyone involved is prepared and understands the course of action to take in a life-threatening situation, reducing anxiety and enabling prompt and appropriate care for the pet.
In the event of a medical emergency, the attending veterinarian will make every effort to contact you regarding treatment. If we are unable to contact you, please indicate if the staff may or may not have permission to proceed with life sustaining procedures. Please keep in mind, if emergency procedures are performed, they will result in additional charges for the treatment or medication that are administered in this circumstance.*

I give permission for life sustaining measures: CPRI DO NOT give permission for life sustaining measures: DNR
Client Policies and Procedures

We want you to be aware of and understand the following policies and procedures for all clients.
What to Expect During Your Pet's Appointment

1. When you arrive for your pet’s appointment, please check in from your vehicle via phone call or text message

This is to help us regulate the amount of people and pets in our small lobby. If there is space available or an open exam room, a team member will instruct you to come inside if you choose

*Curbside and Video Chat Appointments will always continue to be available if you wish to remain in your vehicle for your pet’s appointment

**Please be advised that due to limited space, owners may not always be able to accompany their pet during an appointment with a Veterinary Technician (nail trims, blood draws, vaccine boosters, etc.)

2. Face masks are OPTIONAL for all staff and clients while inside the building. If you would prefer our staff wear a mask while working with you or your pet, please let us know.

If you are exhibiting any symptoms of respiratory illness, we ask that you please wear a mask. If you do not have a face mask, staff will provide you with one to wear throughout the remainder of your pet’s appointment.

3. If you are sick and have tested positive for COVID-19, please notify a staff member immediately. We will ask you to wait in your vehicle for the remainder of your pet’s appointment

Thank you for your patience, cooperation and kindness as we work together to provide your pet with the best possible care!
Would you prefer our staff wear a mask while working with you and/or your pet?*

YesNo Preference
Financial Policy

Our office accepts Visa, Mastercard, Discover, American Express, Care Credit or Cash Payments.

Full payment is due at the time of service. This includes any charges/fees agreed to by you or an authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered. Your signature below indicates your agreement with these policies.
We will gladly prepare a written treatment plan outlining service fees if you desire. All professional fees are due at the time of services rendered. We accept all major credit cards, cash or Care Credit.*

Yes, please provide a treatment planNo treatment plan necessary
Do you have insurance for your pet?*

YesNoNo, but I would be interested in learning more
If you have insurance for your pet, who is your provider?
No-Show, Late & Cancellation Policy

Please click on the link below to review South Hyland Pet hospital's No-Show, Late & Cancellation Policy.

No-Show, Late & Cancellation Policy

Client Rights and Responsibilities

Please click on the link below to review South Hyland Pet Hospital's Client Rights and Responsibilities.

Client Rights and Responsibilities

Treatment Consent

By signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of South Hyland Pet Hospital to examine, prescribe for or treat my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the exception of another veterinary facility.
Health Certificate & CVI Owner/Consigner Acknowledgement

I have read and researched all of the applicable information in regards to what I need as an Owner to travel with or without the animal listed above either foreign or domestically.

I have provided South Hyland Pet Hospital with truthful and accurate information pertaining to the animal listed above as well as any and all details in regards to specific information relating to travel, final destination and recipient of the animal if applicable.

I understand that additional documentation may be required to return to the United Stated with the animal listed above and that this additional documentation may need to be obtained from a veterinarian or other authorized government official from the country of which the animal will be returning.

I understand South Hyland Pet Hospital is not responsible for completing documentation beyond the Certificate of Veterinary Inspection (CVI) unless requested. I will not hold South Hyland Pet Hospital responsible for any additional documentation required for the animal listed above to travel foreign or domestically (other than a CVI) that I did not provide them with.

I understand that CVIs are submitted electronically to the United States Department of Agriculture (USDA), and for the animal listed above to travel internationally, have allowed enough time for it to be endorsed and returned prior to the date of embarkation. I am aware that not all countries accept an electronically signed CVI and assume responsibility of being present at the address listed above to receive and sign for the paper certificate from FedEx.

I accept that I am responsible for any and all fees for the USDA endorsement of a CVI (including FedEx shipping fees for countries that do not recognize electronically endorsed certificates) which is determined by the number of animals traveling/listed on the CVI and any specific requirements and/or testing required by the country of destination prior to entry.

I have made the proper arrangements with the travel provider (airline, cargo ship, etc.) in advance and have determined what their requirements are in regards to the transportation of the animal listed above. I understand and accept that this is not the responsibility of South Hyland Pet Hospital.
Signature*

Clear
Date

MonthDayYear
Date
As soon as we receive this form from you, our team will begin to investigate the requirements for your pet to travel to your specified destination. If we are able to complete the requirements and health certificate within the necessary time frame, we will contact you to collect pre-payment for the health certificate and schedule an appointment.
Should be Empty:

Information for Domestic and International Health Certificates

Information the United States Department of Agriculture REQUIRES to Complete a Interstate and/or International Certificate of Veterinary Inspection (CVI)

Advance Veterinary Care Directive(s)

Client Policies and Procedures