Smithers Animal Hospital - Domestic Health Certificate Form

"*" indicates required fields

Contact Information

Owner Name*

First Last

Owner Phone Number*

Owner Email*

Owner Address*

Street Address Address Line 2 City State ZIP Code

Purchaser / Recipient First and Last Name or Company Name

Purchaser / Recipient or Company Phone Number

Purchaser / Recipient or Company Address

Street Address Address Line 2 City State ZIP Code

Traveling Information

What day will the pet be traveling?*

What method of travel?*

Air Cabin

Air Cargo

Automobile

What airline will the pet be flying?*

Are you traveling with the pet?*

Yes

No

Is the purchaser / recipient picking up or traveling with the pet?*

Yes

No

Is another company transporting the pet for you?*

Yes

No

Transporter First and Last Name or Company Name*

Transporter Phone Number*

Transporter Address*

Street Address Address Line 2 City State ZIP Code

Purpose of movement?*

Adoption

Owner Relocation

Personal Travel

Research

Sale

Exhibition/Show

Training

Other

Pet Information

Pet Name*

Species*

Breed*

Gender*

Color*

Date of Birth or Estimated Age*

Does your pet have a microchip?*

Yes

No

Microchip Number

Traveling within the United States: depending on the age of your pet, many states may require a rabies vaccine prior to travel. You will be informed about that requirement during your appointment.

Traveling out of the United States: please call the clinic to get in touch with a nurse/technician to assist you further.

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