Domestic Travel Health Certificate Form

Pet Owner Worksheet for Preparing Visit with an Accredited Veterinarian to Complete a Continental U.S. Certificate of Veterinary Inspection (CVI/”Health Certificate”)

Please complete this form completely PRIOR to your appointment.

Failure to do so may result in delayed processing. Proof of vaccines can be emailed to us at info@heartlandveterinaryil.com. Please note that each state has unique requirements for the transportation of animals. It is the pet owner’s responsibility to research requirements for their pet.

Heartland Veterinary Hospital does not organize or research travel requirements.You must visit https://www.aphis.usda.gov/pet-travel/state-to-state prior to completing this form or your pet's travel plans. Enter the state of your destination on this site to start planning what is needed for you and your pet to safely travel together.

First

Last

Pet Name (one pet per form):

Pet Date of Birth (Estimate if exact DOB is not known):

Pet Gender:

Species:

Phone Number:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County of destination (not Country):

E-Mail Address:

Pet Date of Travel:

Does your pet have a microchip?

Yes

Unknown

If you answered yes, please enter microchip number (enter N/A if no chip):

Where was your pet's last rabies vaccination given? *If answering "b" a copy of proof of rabies vaccine MUST be submitted to Heartland. Acceptable proof include county-issued rabies certificate or records from a licensed veterinarian. Images of rabies tags are not proof of vaccine.

If you answered "b" in previous question, where was your pet's last rabies vaccination given?

Has your pet bitten anyone within the last 10 days?

Yes

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Domestic Travel Health Certificate Form

Please complete this form completely PRIOR to your appointment.

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