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INTERNATIONAL CERTIFICATE OF HEALTH EXAMINATION FOR SMALL ANIMALS

1. TYPE OF ANIMAL SHIPPED


Dog  Cat  Other  If other, specify:_______________________

2. TOTAL NUMBER OF ANIMALS

3. NAME, ADDRESS, AND TELEPHONE NUMBER OF OWNER/CONSIGNOR

4. ANIMAL IDENTIFICATION
MICROCHIP/TATTOO/NAME BREED AGE SEX COLOR
1)
2)
3)
4)
5)

5. VACCINATION HISTORY
RABIES OTHER VACCINATIONS, TESTS, OR TREATMENTS
DATE PRODUCT DATE TYPE/RESULT
1)
2)
3)
4)
5)

VETERINARY CERTIFICATION: I certify that the animal(s) described in item 4 have been examined by me this date, that the
information in ITEM 4 is true and accurate to the best of my knowledge, and that the following findings have been made “X”
applicable statements.

 I certify that the animal(s) described have been inspected by me this date and appear to be free of any infectious diseases
and to the best of my knowledge exposure there to which would endanger the animal or animals or would endanger public
health.

 I certify that the animal(s) described above have been inspected by me this date and appear to be free of physical
abnormalities which would endanger the animal(s).

 To my knowledge the animal(s) described above originated from an area not quarantined for rabies and have not been
exposed to rabies.

NAME, ADDRESS, AND TELEPHONE NUMBER OF ISSUING VETERINARIAN:

SIGNATURE: DATE: