Health Certificate Questionnaire

Please fill the following form out completely and accurately. This information will be used to complete your pet’s health certificate. Any incomplete or incorrect information will delay the health certificate process and may affect your travel plans.

health certificate questionnaire

Intended destination

Date of intended departure

Consignor/Local Owner Information

Full name

Local Address

City

State

ZIP/Postal

Local Phone Number

Consignee/Destination Owner Information

Full name

Destination address

City

Country

Destination phone number

Pet Information

Name

Date of birth

Sex

Spay/Neuter

Yes

Species

Canine

Feline

Microchip number

Date microchip placed

Date Vaccines Were Administered Last

Rabies

Bordetella (canine)

DHPP (canine)

Leptospirosis (canine)

FVRCP (feline)

Feline Leukemia

We must have hard copies of your pet’s Rabies certificate and other vaccinations at least 48 hours prior to the date of the health certificate examination if vaccinations were not performed at Triangle Animal Clinic. Any vaccines not current or without proper documentation will need to be updated based on destination requirements before the health certificate can be issued. Some countries have a waiting period after vaccination before an animal can be admitted to the country.

Agree

Does your destination require vaccine titers? Obtaining vaccine titers is a process that can span weeks or months. Please research the requirements of your destination country thoroughly.

Yes

Heartworm prevention name

Date last given

External parasite prevention name

Date last given

Internal parasite treatment required?

Yes

Product required

Date required

Many countries recommend specific products be used at pre-determined timelines, and may require application or administration of medications to be supervised by a veterinarian. Please be sure to contact the USDA for specific guidelines based on your travel plans. Health Certificates are legal documents and must be accurate and precise. It is extremely important that all research is done and all information made available prior to the time the health certificate is needed. Missing information or failing to meet requirements may result in denial of entry of the pet in question into the country and/or delays and expenses that will affect travel plans. Please note: our veterinarians retain the right to deny endorsement of a Health Certificate if all of the requirements have not been met. It is the responsibility of the pet owner to obtain and provide information on all requirements and any necessary records. The health certificate process can be complicated and time consuming. Please contact the USDA for any questions or concerns you might have regarding this process. This form and accompanying documents must be received at least 48 hours prior to the date of the health certificate examination.

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Health Certificate Questionnaire

Consignor/Local Owner Information

Consignee/Destination Owner Information

Pet Information

Date Vaccines Were Administered Last

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