Health Certificate Application

Health Certificate Application

Application Form - one form per pet
Please complete the form including file uploads and we will contact you to schedule an appointment to examine/inspect your pet.

If your pet is not an existing patient, then you should first gather your pets most recent health documents (vaccinations, tests, and parasite control dates) from your current or previous veterinarian.

This form typically takes 5 to 10 minutes on average to complete if information is gathered before completing it.
Is your pet already a patient at Parkland Veterinary Hospital?*
What type of Health Certificate are you looking for?*
Pet Owner's Full Name*

First NameLast Name
Phone Number*
E-mail*
Pet's Name*
Travel Information
How soon do you plan to travel?*

MonthDayYear
Enter the actual, desired, estimated, or best guess date
Any usefull comments about your travel plans or arrangements?
Name of Airline for your Flight (if known) *
If not known then write UNKNOWN
Is there an Airline form to be completed?*

YesNoDon't Know
Upload Airline Form if Available (Pdf, Doc, or Docx files only)

Browse Files
Click button to begin file upload. Maximum file size if 5MB Cancelof

Pet Information
Microchip Number
Date of Birth*

MonthDayYear
Date
Color(s)*
Breed*

Description*

	Species	Sex	Intact?
Description

Vaccination Information

Most Recent Date Vaccine Given
Rabies Vaccination

MonthDayYear
Date Given
Distemper Adenovirus Parvovirus Parainfluenza(DAPP / DA2P)

MonthDayYear
Date Given
Bordatella (Kennel Cough)

MonthDayYear
Date Given
Leptospirosis

MonthDayYear
Date Given
Comments about vaccines:

Testing Information

Most Recent Date Tests Completed if Applicable
Heartworm Test

MonthDayYear
Date Completed
Fecal Test

MonthDayYear
Date Completed
Rabies Titer Test

MonthDayYear
Date Completed
Bloodwork Test

MonthDayYear
Date Completed
Comments about tests:
Parasite Control Information

Most Recent Parasite Control
Name of Heartworm and Intestinal Parasite Prevention
Date of Heartworm and Intestinal Parasite Prevention

MonthDayYear
Date Given
Name of Flea and Tick Prevention
Date of Flea and Tick Prevention:

MonthDayYear
Date Given
Comments about parasite controls:
Upload Medical/Vaccination/Test/Parasite-Control records if Available

Browse Files
Click button to begin file upload. Pdf, Doc, or Docx files only. Maximum file size if 5MB Cancelof

Originating Location
Name of Person Traveling/ Transporting pet (Consignor):*

First NameLast Name
Consigner's Phone Number*
Embarking / Originating Airport
Originating U.S. Address*

Street Address

Street Address Line 2

CityState

Zip Code
Destination Location
Name of Person Arriving/ Recieving pet (Consignee):*

First NameLast Name
Cosignee's Phone Number*
Disembarking / Destination Airport
Destination Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
New Client Agreement (Please read before signing):*
Client Agreement to Terms and Policies in Care of Patient(s): Please read carefully before signing. I give Parkland Veterinary Hospital permission to release any pertinent information about my pet to other veterinary health care providers or those people whom I have entrusted with the care of my pet. I understand that payment is expected for all services at the time they are performed. For your convenience we accept all major credit cards (signed), debit cards, cash, Care Credit, pet insurance, and first party permanent local checks (with ID, established clients only, and any returned/bounced checks are charged a fee of $29 with lost privileges for future check payments). We do not do billing plans due to the high cost of managing such plans and so that the cost is NOT passed on to our customers. Payment is due when services are rendered. In some cases, a deposit may be necessary. Clients are encouraged to discuss estimates before services are rendered. Please note that we offer cost savings through our Wellness Packages and we encourage clients to take advantage of these plans. A photo ID (such as driver’s license) is required for drop-off or pickup of all animal patients. I, the undersigned, assume financial responsibility as stated above, I have read, understand, and agree to the terms.
Signature
Should be Empty:

Health Certificate Application

Travel Information

Pet Information

Vaccination Information

Testing Information

Parasite Control Information

Originating Location

Destination Location