International Health Certificate Information Form

Owner's Legal Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day Time Phone
Evening Phone
Mobile Phone
Email
Confirm Email
Date of Birth
Date Format: MM slash DD slash YYYY
Co-owner's Legal Name
First Last
Co-owner's Primary Phone
Pet's Information
Pet's Name
Sex
- Spayed Female
- Intact Female
- Neutered Male
- Intact Male
Species
Breed (if known)
Color
Date of Birth/Age (if known)
Microchip number:
Microchip Implantation date
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of all RABIES vaccine
Other vaccinations given?
Do you have signed Rabies certificate for your pet? (not reminder or receipt): if yes, please attach.
Does your pet have EU pet passport? If yes, please attach.
Is owner traveling with the pet in the same plane? If not, please enter name of the person traveling with pet:
First Last
Is pet going with cargo?
Destination country? (where owner and pet clearing customs)
Travel date:
Please do not email us health certificate forms, we will fill those out at our end.

One of our health certificate specialists will be in contact with you within 1-2 business days.

Thank you for contacting Beverly Robertson Veterinary Clinic

Pet's Information