Please note that if your departure date is within the next 14 days, we cannot guarantee we will be able to assist with your travel inquiry. A team member will reach out to confirm your request. *

I have read the above statement and understand that my health certificate may not be completed within 14 days due to various circumstances.

Client Information

Name *

Name

First

Last

Choose Hospital Location *

Phone *

Email *

Address *

Address

City

State/Province

Zip/Postal

Pet's Name *

Pet Information

Species *

Dog

Cat

Sex *

Male

Female

Spayed/Neutered *

Yes

Breed *

Color *

Age *

Would you like to upload your pet's medical record OR provide the name of your previous animal hospital? *

Upload Medical Records

Previous Animal Hospital

Medical Records

Please upload Medical history/records

Maximum file size: 52.43MB

Please upload vaccine history/records

Maximum file size: 52.43MB

Name of your previous animal hospital *

Have you booked a flight? *

Yes

Scheduled Travel Information

Destination Country *

Other countries to be visited during this trip *

Date of departure *

Airport of Departure *

Time of Departure *

Date of arrival *

Airport of arrival *

Airline *

Will pet travel in cabin or cargo? *

Cabin

Cargo

Name of person traveling with pet (as name appears on passport) *

Name of person traveling with pet (as name appears on passport)

First

Last

Additional person traveling with pet

Current U.S. Address of person traveling with pet

City

State/Province

Zip/Postal

Phone number of person traveling with pet *

Destination Address *

Destination Address

City

State/Province/Region

Postal Code

Country

Reachable phone number in destination *

Future Travel Information

What is your expected travel date? *

What is your expected destination country? *

Do you have additional questions for our Travel Team? *

Does your pet have a European Union Pet Passport? *

Yes

Are you moving permanently? *

Yes

Date of Return *

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of my pet(s). I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospital treatment. *

I have read and agree

I certify that I am the legal owner/agent of the above-mentioned pet(s) and I am hereby assuming all financial responsibility for treatment given to this animal by Heart of Chelsea Veterinary Group *

I have read and agree

I hereby authorize the release of my pet’s medical records to another facility (boarding/daycare, insurance company, urgent care facility, etc.), should they be requested. *

Yes

By selecting yes, I hereby grant Heart of Chelsea Veterinary Group permission to take photographs of myself and/or my pet and to publish those photographs for any lawful purpose, including, but not limited to, their website, social media accounts, and promotional materials, either digital or in print. I also grant permission to use my pet’s name. Heart of Chelsea Veterinary Group will remove any published photo(s) previously consented to at the owner’s request. I authorize Heart of Chelsea Veterinary Group to edit and share the aforementioned photograph(s). I also waive any rights of privacy or compensation associated with the use of my or my pet’s image(s) and name(s) for the personal or commercial purposes outlined above. *

Yes

Signature *