International Health Certificate Preliminary Questionnaire Date* MM slash DD slash YYYY Patient's Name (first and last, please).*Phone Number*DESTINATION INFORMATIONWhat is the complete address of your final destination?*Do you know your planned departure date?* Yes I'm not sure When is your planned departure date?* MM slash DD slash YYYY Do you know when you expect to arrive at your destination?* Yes I'm not sure When do you expect to arrive at your destination? MM slash DD slash YYYY Do you know what airport you are leaving the United States from?* Yes I'm not sure What airport are you leaving the United States from? (i.e. direct flight from AUS or AUS→IAH (Houston) or AUS→ALT (Atlanta), etc.)*Do you know what airline(s) you are using?* Yes I'm not sure What airline(s) are you using?*Are you returning to the USA?* Yes No I'm not sure When are you returning to the USA?Are you returning to Texas?* Yes No I'm not sure What is the address of your residence in the USA?*PERSON'S INFORMATIONWhat is your full name on your personal passport?*If you're traveling with a partner/spouse, what is the full name on their personal passport?*Will your pet(s) be on the same airplane as you?* Yes No PET INFORMATIONWhat pet(s) are traveling with you?*Any current/ongoing medical conditions?*List all current medications and supplements being administered*Please email all (non-PAZ) previous medical records to staffwest@pazvet.com or attach to this form. Drop files here or Select files Max. file size: 512 MB. You're finished! Please press the submit button. We look forward to seeing you!
