Travel Health Certificate Form – Union Pet Hospital

Owner's Name *

First

Last

Email *

Owner's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Domestic or International travel? *

Method of travel? *

Reason for travel? *

Other: *

Date of Travel Departure *

Travel Destination Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Duration of Visit *

Pet's Name *

Pet's Date of Birth or Age *

Pet's Gender *

Pet's Microchip Number *

Vaccination History

Previous veterinarian can send information to email Info@Unionpethospital.com or FAX to 859-384-7702 OR complete the information below.

Pet’s Vaccination History and Dates of Vaccinations:

Supply specific vaccination names, serial numbers, and date administered.

Once completed, you will need to call the office to pre-pay the travel certificate fee. *

Travel Health Certificate Questionnaire