Section 1: Owner and Travel Contact InformationOwner's Full Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please provide your U.S. mailing address (not the destination address). For some health certificates, the USDA mails the document directly to the client prior to travel, and it must be signed for upon delivery.Country: USA Please note that we will be unable to complete health certificates for patients currently residing outside of the USPhone Number(Required)Email Address(Required) Section 2: Travel Companion Information(Complete if someone other than the owner will accompany the animal)Will the owner be traveling with the animal?(Required) Yes NoTraveler’s Full Name(Required) First Last Relationship to Owner(Required)US Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(Required)Email Address(Required) Section 3: Pick up Contact information (Complete if someone other than the owner will pick up the animal at the destination)Important:This information applies to every leg of the journey.If there is a layover where the pet will be picked up (and not remain in transit), we will need the full name, email, and phone number of the person responsible for pick-up at each location. This is only required if the pet is not traveling with the owner or a person listed in Section 2, and will instead be picked up by someone else at the airport or destination.Will the owner be picking up the animal?(Required) Yes NoPickup Person’s Full Name(Required) First Last Relationship to Owner(Required)Phone Number(Required)Email Address(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Section 4: Travel ItineraryImportant: You must inform us of all locations your pet will travel through, including any layovers in other countries or U.S. states (even if landlocked) before reaching your final destination. Health certificate requirements may differ for each location, and all applicable requirements must be met for every stop in your pet’s journey — not just the final destination. Please indicate in the “Other” section if multiple layovers occur.Departure Airport Name(Required)Departure Date(Required)Return Date (if applicable) MM slash DD slash YYYY Layover InformationPlease write N/A if this does not apply. Address is only needed if the animal will be staying overnight at a hotel, house, etc. or if you are landing in one country, and using other transport methods to travel to your destination countryLayover Country/ State(Required)Dates (if applicable) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Will any other counties or locations be visited during this trip?(Required) Yes No(If YES we will need “Destination Information” for EACH destination of the trip)Section 4: Travel Itinerary: Additional Layover & Destination InformationPlease only complete this section if more than one layover and/ or destination will be traveled to.Additional Layover InformationAddress is only needed if the animal will be staying overnight at a hotel, house, etc.2nd Layover Country/ State:(Required)Dates (if applicable)(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Any Additional Layovers(Required) Yes No(If YES we will need the above information for EACH layover)Additional Destination Information2nd Destination Country(Required)Destination City & State/ Province:(Required)Full Address Where Pet Will Be Staying:(Required)Dates at 2nd destination:(Required) MM slash DD slash YYYY Section 5: Transportation MethodMode of Travel (Check all that apply)(Required) Airplane Ship Other (e.g. car, train)Airline Name(s)(Required)Flight Number(s)(Required)Will the pet travel in:(Required) Cargo Cabin (carry-on)Name of Cruise Line or Vesse(Required)Departure Port(Required)Arrival Port(Required)Other (e.g. car, train)If your pet’s trip includes layovers, please list the transportation method used for each leg of travel. If flying, list ALL flight numbersDepartureArrivalBorder Crossing PointSection 6: Animal Information(One form per pet. Please complete one for each traveling animal)Pet’s Name(Required)Species(Required) Canine Feline OtherPlease Specify(Required)Breed:(Required)Color/ Markings:(Required)Date of Birth (or Age):(Required)Microchip Number:(Required)Microchip Implantation Date:(Required)Rabies InformationRabies Vaccination Date(Required)Rabies Certificate Serial #(Required)Rabies Vaccination Valid Through(Required)Type of Rabies(Required) 1 Year 3 YearsHas a Rabies vaccine been given prior to the above vaccination?(Required) Yes NoIf yes, list all former vet clinics where a Rabies Vaccine was administered(Required)Is the pet traveling back to the US?(Required) Yes NoHeartworm Prevention**Please write N/A if one of the below questions do not apply**Name of current heartworm prevention:(Required)Last Date heartworm prevention was given:(Required)Flea/ Tick Prevention**Please write N/A if one of the below questions do not apply**Name of current flea/ tick prevention:(Required)Last date flea/ tick prevention was given:(Required)Intestinal Parasite Prevention**Please write N/A if one of the below questions do not apply**Name of current intestinal parasite prevention:(Required)Last date intestinal parasite prevention was given:(Required)Canine Health History InformationThis section helps us prepare your pet’s health certificate efficiently. If traveling with a feline, proceed to pages 9 & 10.Important:Please have your pet’s previous medical records sent directly to: clinic@amethystvets.com.If Amethyst Veterinary Clinic did not provide any of the care listed below, we must have official veterinary records showing the date the service or treatment was performed.Select “No” for items your pet has never received.Not all destinations require every item listed; however, providing complete and accurate information will help us expedite the process and reduce the likelihood of delays.Rabies Vaccine:(Required) Yes, current No Yes, but not current(attach Rabies Certificate)Distemper Combination (DAPP or DA2PP) Vaccine(Required) Yes, current No Yes, but not currentLeptospirosis Vaccine(Required) Yes, current No Yes, but not currentBordetella Vaccine(Required) Yes, current No Yes, but not currentHeartworm Testing:(Required) Yes, current No Yes, but not current(please note: retesting may be required if your pet has not been on consistent heartworm prevention)Fecal Testing:(Required) Yes, within the last 6 months No Yes, but not within the last 6 months(intestinal parasite screening)Bloodwork:(Required) Yes, within the last year No Yes, but over a year ago(titers, general health profiles, etc)Routine Parasite Prevention(Required) Yes, within the last month No Yes, but over a month ago(heartworm, flea, and/or tick)Routine Intestinal Parasite Deworming(Required) Yes, within the last 6 months No Yes, but over 6 months agoMicrochipping(Required) Yes NoDate placed:(Required)Microchip Number:(Required)Section 7: Additional NotesPlease include any other relevant information about your pet, such as:Health concerns or chronic medical conditions (e.g., seizures, heart murmurs, arthritis)Current medications, including anxiety medications needed for travelSpecial handling requirementsKnown allergiesUnique travel requirements specified by your destinationEnter details hereFeline Health History InformationThis section helps us prepare your pet’s health certificate efficiently. If traveling with a CANINE, return to pages 7 & 8.Important:Please have your pet’s previous medical records sent directly to: clinic@amethystvets.com.If Amethyst Veterinary Clinic did not provide any of the care listed below, we must have official veterinary records showing the date the service or treatment was performed.Select “No” for items your pet has never received.Not all destinations require every item listed; however, providing complete and accurate information will help us expedite the process and reduce the likelihood of delays.Rabies Vaccine:(Required) Yes, current No Yes, but not current(attach Rabies Certificate)Feline Distemper (FVRCP) Vaccine(Required) Yes, current No Yes, but not currentFeline Leukemia (FeLV) Vaccine(Required) Yes, current No Yes, but not currentFIV/ FeLV Testing:(Required) Yes, within the last year No Yes, but over a year agoFecal Testing:(Required) Yes, within the last 6 months No Yes, but not within the last 6 months(intestinal parasite screening)Bloodwork:(Required) Yes, within the last year No Yes, but over a year ago(titers, general health profiles, etc)Routine Parasite Prevention(Required) Yes, within the last month No Yes, but over a month ago(heartworm, flea, and/or tick)Routine Intestinal Parasite Deworming(Required) Yes, within the last 6 months No Yes, but over 6 months agoMicrochipping(Required) Yes NoDate placed:(Required)Microchip Number:(Required)Section 7: Additional NotesPlease include any other relevant information about your pet, such as:Health concerns or chronic medical conditions (e.g., seizures, heart murmurs, arthritis)Current medications, including anxiety medications needed for travelSpecial handling requirementsKnown allergiesUnique travel requirements specified by your destinationEnter details hereClient International Health Certificate/ U.S. Island Intake FormAcknowledgment & Privacy StatementI confirm that the information provided in this form is true and accurate to the best of my knowledge. I understand that this form is the first step in the international or U.S. island travel preparation process, and that additional steps, documentation, and veterinary appointments may be required based on the requirements of my pet’s destination and any layover locations. I acknowledge that failure to provide accurate or complete information may result in travel delays or denial of entry for my pet.I understand that this form is not an official health certificate. It is an intake and information-gathering tool used by Amethyst Veterinary Clinic to collect the details necessary to prepare my pet’s official health certificate. The official health certificate will be completed, signed, and issued by a USDA-accredited veterinarian only after all required examinations and verification of records have been completed. Competition of requirements, submission of health certificate, and any other documents, does not guarantee endorsement by the USDA. I understand that once any documents are submitted to the USDA for endorsement, Amethyst Veterinary Clinic is not responsible for the endorsement, timeframe, and return of the documents to the owner as this is the responsibility of the USDA.Privacy Notice: The information provided in this form will be used solely for the purpose of preparing and processing my pet’s health certificate and related travel documentation. It will not be shared or used for any other purpose, except as required by law or by governing authorities for animal transport and import/export compliance.Signature(Required)Date(Required) MM slash DD slash YYYY Δ
