Health Certificate Information - Van Dyke Animal Clinic

Pet information
Name*
Breed ( as specified on rabies certificate)*
Microchip #*
DOB*
Spayed/ neutered*
- Yes
- No
Please enclose rabies certificate with date of vaccination, name of vaccine used, lot number and expiration of vaccine
Owner information/traveling with pet
Your Name (must match passport )*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Traveling with pet ?*
- Yes
- No
Address at destination*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone at destination*
If pet is traveling alone, name of person receiving pet at destination
First Last
Date of travel*
MM slash DD slash YYYY
Departure city*
Mode of transport (flying, cruise , auto)*
Will the pet be in transit in a different country than final destination?*
- Yes
- No
If yes, state country*
Will the pet be returning to the US?*
- Yes
- No
Date of return travel
MM slash DD slash YYYY
For pets returning to the US, in addition to USDA endorsed documents which we will provide, your pet will need to have a current Rabies vaccine and microchip, and you will need to register with the CDC using the following links:
CDC Animal Importation Form | Dog Import Form Instructions
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Phone
This field is for validation purposes and should be left unchanged.

Pet information