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*
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Pet information