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801-487-9981
2206 S McClelland St, Salt Lake City, Utah
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Health Certificate Worksheet
This worksheet must be completed before your pet’s appointment to obtain a Health Certificate for travel.
It is important to check the following website to obtain the proper information to complete this worksheet.
Pet Owner’s Name
*
First
Last
Phone Number
*
Email
*
Pet Name #1
*
Pet Name #2
Date
*
Date Format: MM slash DD slash YYYY
Current Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Who is accompanying your pet while traveling?
*
(name & relationship to owner)
Destination Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
How is your pet traveling?
*
Airplane - direct flight
Airplane - connecting flights
Car
Train
Boat - direct
Boat - Cruise ship with multiple stops in other countries
If traveling via cruise ship, please list all countries the ship will be docking.
What is the reason for travel?
Relocation, work, vacation, etc.
What date is your pet leaving?
Date Format: MM slash DD slash YYYY
What is the arrival date for your pet?
Date Format: MM slash DD slash YYYY
What is the arrival date for yourself?
Date Format: MM slash DD slash YYYY
What is the return date?
Date Format: MM slash DD slash YYYY
Name pet(s) who are traveling:
Pet Name #1
Pet Name #2
Pet #1 Birthdate
*
MM
DD
YYYY
Pet #2 Birthdate
MM
DD
YYYY
Does your pet have a microchip?
*
Yes
No
I don't know
If yes, what is the microchip number & where is it registered?
Is your pet currently taking a flea/tick preventative?
*
Yes
No
Is your pet currently taking a heartworm preventative?
*
Yes
No
Please list the product name(s) and frequency given:
Dose your pet need medication for travel?
*
Yes
No
Not sure
Is your pet current on it's Rabies Vaccination?
*
Yes
No
Not sure
Previous Veterinary Hospital / Clinic Name & Phone Number
*
Upload pets Medical / Vaccination Records
Please list the medication name(s), frequency given, and prescriber’s name:
*
INTERNATIONAL TRAVELERS: Does your destination country require an import permit?
Yes
No
I don't know
INTERNATIONAL TRAVELERS: Did your airline or cruise ship give you any additional travel requirements for your pet(s)?
Yes
No
I don't know
Please list any additional health history, comments, or information you’d like to share:
Δ
About Us
Our Team
Promotions
Careers
Hospital Services
Diagnostic Services
Surgery Services
Dentistry
Anesthesia
Nutrition
Allergies
End of Life Care
Wellness Center
General Wellness
Microchipping
Parasite Control
Additional Services
Pet Health
Pet Health Checker
Pet Health Library
Pet Food Recalls
Pet Insurance
Product Recalls
How-To Videos
News
Mobile App
Payment Options
Forms
New Client Registration Form
Health Certificate Worksheet
Online Pharmacy
Purina Vet Direct
Shop Online
Contact
Make an Appointment
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