Interstate Travel Questionnaire

Local Contact information for person traveling with or shipping pet (*form must be 100% completed before submitting)

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Enter Email Confirm Email

Is this the same address at which the pet currently resides?*

Yes
No

If no, what is the address where pet currently resides?*

Street Address Address Line 2 City State ZIP Code

Traveling pet’s name:*

Breed:*

Age of Pet:*

Current Weight:*

Gender:*

Male/Neutered
Male/intact (not altered)
Female/spayed
Female/intact (not altered)

Is pet microchipped?*

Yes
No

If yes, please provide microchip number:*

Do you have a copy of your pet’s current rabies certificates with vaccination expiration date?*

Yes
No

Purpose of travel:*

Mode of Travel:*

If air travel, list the airline(s) you are flying with pet (Note: it is REQUIRED that you review individual airline requirements for pet travel prior to any vet visits):

Have you contacted the airline or carrier (boat, train, etc.) to see if they have required supplemental forms that Nipomo Dog and Cat hospital will need to complete prior to travel?*

Yes
No

(NOTE: if you selected “no”, it is REQUIRED that you know this information prior to any vet visits)

Have you reviewed the carrier’s pet travel policies?*

Yes
No

(NOTE: if you selected “no”, it is REQUIRED that you know this information prior to any vet visits)

Anticipated departure date:*

Is it a one-way trip?*

Yes
No

If you selected “no”, how long do you think your pet will stay there?*

Which state are you traveling TO?*

How is your pet traveling?*

With me
With someone else
Alone and being picked up by someone else

*If pet is not traveling with you, who will be traveling with your pet or who will be picking pet up (please complete information below of this person)?

Name of contact person:*

First Last

Phone # of contact person (area code first):*

Email of contact person:*

Enter Email Confirm Email

Address of contact person:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Destination address:*

Street Address Address Line 2 City State ZIP Code

Destination phone # (area code first):*

Traveling through/stopping in multiple states?*

Yes
No

If “yes”, list all states:*

Are you aware of any medical or behavioral issues regarding your pet that we should be aware of?*

Yes
No

If "yes", please explain:*

Do you anticipate that your pet will need some type of travel anxiety medicine prescribed?*

Yes
No

Do you anticipate that your pet will be traveling as an emotional support pet?*

Yes
No

If “yes”, have you traveled with this pet as emotional support in this way before? (select one)*

Yes
No

If “yes”, do you have an official documentation from a physician supporting this? (select one)*

Yes
No

Local Contact information for person traveling with or shipping pet (*form must be 100% completed before submitting)

Ready to become part of the family at Nipomo Dog & Cat Hospital?

Ready to become part of the
family at Nipomo Dog & Cat Hospital?