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Hours 1830 Polk Street
San Francisco, CA 94109

Health Certificate Form

Full name of SINGLE person traveling with pet(s)*

Complete Address of DESTINATION*

My pet and I are*

Permanently Relocating

Temporarily Visiting

Re-entry

Telephone of Destination (if applicable)

Port of Departure*

Port of Destination*

Date of Departure*

Will your pet be traveling with you or in cargo*

What airline are you flying?*

Pet Information

Pet Name*

Dates of last 3 Rabies Vaccination*

Microchip Number and Date of Placement*

Polk Street Animal Hospital