Health Certificate Questionnaire

Pet Name:*

What is the species, breed, and color of your pet?*

Species:
Breed:
Color:

Pet Birthdate:*

Sex:*

Female

Female, Spayed

Male

Male, Neutered

Does your pet have a microchip?*

yes

no

I don't know

If your pet has a microchip, when was it implanted?

Please list the destination country you are traveling to with your pet:*

Please list the address and phone number in the destination country where your pet will stay:*

Address:
Phone Number:

Airline (If known)*

Estimated date of flight (does not have to be scheduled)*

Does your flight layover in EU?*

Yes

No

Port of Embarkation (this is the airport where the international leg of the flight is leaving from, not necessarily the same airport where the trip starts)*

Cabin or Cargo?

Permanent Import, temporary admission, or re-entry?*

Is the patient on Heartworm, Flea or Tick Medication?*

Yes

No

If yes, please provide the name of the product(s) and last date of administration:

Heartworm:
Flea:
Tick:

What are the dates of your pet's last 2-3 rabies vaccinations?*

1.
2.
3.

Health Certificate Questionnaire

Pet Name:*

What is the species, breed, and color of your pet?*

Pet Birthdate:*

Sex:*

Does your pet have a microchip?*

If your pet has a microchip, when was it implanted?

Please list the destination country you are traveling to with your pet:*

Please list the address and phone number in the destination country where your pet will stay:*

Airline (If known)*

Estimated date of flight (does not have to be scheduled)*

Does your flight layover in EU?*

Port of Embarkation (this is the airport where the international leg of the flight is leaving from, not necessarily the same airport where the trip starts)*

Cabin or Cargo?

Permanent Import, temporary admission, or re-entry?*

Is the patient on Heartworm, Flea or Tick Medication?*

If yes, please provide the name of the product(s) and last date of administration:

What are the dates of your pet's last 2-3 rabies vaccinations?*

If unknown, please tell us the name of the clinic where these vaccines were given

Date of last FAVN (Rabies titer) if applicable