Midvalley Animal Clinic
607 S Redwood Road
Salt Lake City Utah 84123 US
8012691213
info@midvalleyanimalclinic.com

EMAIL CALL

Health Certificate Form

CLIENT DETAILS

First name ^*

Last name ^*

Email ^*

Phone ^*

Address ^*

PATIENT DETAILS

Patient name ^*

Patient species ^*

Patient breed ^*

Patient color ^*

Patient gender (e.g. male, female, unknown) ^*

Patient DOB or age ^*

Patient weight

Patient microchip

Is your pet traveling outside of the United States, to Hawaii, or Alaska? ^*

Is your pet traveling outside of the United States, to Hawaii, or Alaska?^*

Yes - STOP - Midvalley Animal Clinic does not offer international health certificates. If your destination is outside of the continental United States, including Hawaii or Alaska, this service is not available through Midvalley Animal Clinic, and you will need to make other arrangements with a USDA- accredited veterinarian. Please visit, www.aphis.usda.gov/pet-travel/us-to-another-country-export, for more information.

No - Continue to the next question

Midvalley Animal Clinic does not offer international health certificates

Travel Certificate Information: Midvalley Animal Clinic and its accredited veterinarians are only able to provide a Companion Animal Certificate of Veterinary Inspection (Health Certificate) for domestic travel within the continental United States. Hawaii and Alaska are excluded and are considered international travel, which requires different documentation and travel criteria. Midvalley Animal Clinic does not offer international health certificates. If your destination is outside of the continental United States, including Hawaii or Alaska, this service is not available through Midvalley Animal Clinic, and you will need to make other arrangements with a USDA- accredited veterinarian. Please visit, www.aphis.usda.gov/pet-travel/us-to-another-country-export, for more information.

Origin Information - THIS IS WHERE YOU ARE LEAVING FROM IN UTAH

Date of Health Certificate Appointment ^*

Origin Physical Address: ^*

Contact Person at Origin: ^*

Phone Number ^*

City ^*

State ^*

ZIP ^*

Destination Information - THIS IS THE PLACE YOU ARE TRAVELING TO

Contact Person at Destination ^*

Phone Number ^*

Destination Physical Address: ^*

City ^*

State ^*

ZIP ^*

Carrier Information

Carrier Name (Transporter) ^*

Type of Animal Shipped^*

Dog

Cat

Shipping Date ^*

Number of animals in shipment ^*

Shipment Information

Animals are traveling with owner

Returning to Utah

Not returning to Utah

Rabies Vaccine Information

Rabies Vaccine Information: Please bring your pet’s most recent vaccine records to your appointment if they were completed outside of Midvalley Animal Clinic. You can also submit records ahead of time to info@midvalleyanimalclinic.com. Proof of a current rabies vaccine is required for any pet 12 weeks of age or older. There are no exceptions to this and it is a requirement in order to have a health certificate.

Is your pet current on rabies?^*

Unsure

Yes

Rabies Vaccination Date (REQUIRED IF 12 WEEKS OR OLDER)

Rabies Expiration Date

Name of vet clinic where the rabies was administered?

Pet Health Information

Your pet will be inspected by an accredited veterinarian of Midvalley Animal Clinic. In order for the veterinarian to issue the Companion Animal Certificate of Veterinary Inspection (Health Certificate), your pet must not be showing any signs of infectious, contagious, and/or communicable disease.

I understand my pet to be free and clear of any infectious, contagious, and/or communicable diseases.^*

Yes

Please sign here^*

Clear

Date

Security Verification

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