Emergencies
805.658.7387
4547 Telephone Rd., Ste A, Ventura, CA 93003 (
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)
info@ohanapethospital.com
805.933.1341
957 Faulkner Road, Suite 101, Santa Paula, CA 93060 (
map
)
infosp@ohanapethospital.com
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Dr. Janis Shinkawa
Dr. Jill Muraoka Lim
Dr. Nicci Quinn
Dr. Donnalee Dorman
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Dr. Amy Vlazny
Dr. Lisa Kentfield
Dr. Marnie Burgoyne
Dr. McKenzie Rasmussen
Dr. Karalyn Kane
Dr. Steffani Klittich
Dr. Jon Dickson
Dr. Allie Jones
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Interstate Travel Questionnaire
Interstate Travel Questionnaire
Health Certificate - Interstate Travel Questionnaire
If you are human, leave this field blank.
Local contact information for person traveling with or shipping pet
First Name
*
Last Name
*
Address Line 1
*
Address Line 2
*
Phone
*
Is this the same address at which the pet currently resides
(select one)
Yes
No
Pet's Primary Address
*
Pet's Primary Address - line 2
*
Email
*
Traveling pet's name (one form per pet, please)
*
Breed
*
Age
*
Gender
*
(select one)
Male Neutered
Male Unaltered (not neutered)
Female Spayed
Female Unaltered (not spayed)
Is pet microchipped?
*
(select one)
Yes
No
Please provide microchip number
*
Do you have a copy of your pet's current rabies certificates with vaccination expiration date?
*
(select one)
Yes
No
Purpose of travel
*
(select one)
Personal
Business
Pet Training
Other
Purpose of travel
What is your anticipated departure date?
*
Is it a one-way trip?
*
(select one)
Yes
No
If no, how long do you anticipate your pet being away?
*
What state are you traveling TO?
*
If your pet is not traveling with you, who will be traveling with or receiving the pet?
Destination Address
*
Destination Address - line 2
*
Destination Phone Number
*
Mode of travel
*
Air
Car
Boat
Train
Other
Mode of travel
Will you be traveling through/stopping in multiple states?
*
(select one)
Yes
No
Which states will you be traveling THROUGH?
*
Have you contacted the airline or carrier (boat, train, etc.) to see if they have required supplemental forms that Ohana Pet Hospital will need to complete prior to travel?
*
(select one)
Yes
No
Have you reviewed the carrier's pet travel policies?
*
(select one)
Yes
No
Which airline are you flying?
*
Has your pet ever flown before?
*
(select one)
Yes
No
Where have they traveled on the airplane?
*
in the cabin
in cargo
Are you aware of any medical or behavioral issues regarding your pet that we should be aware of?
*
(select one)
Yes
No
Please explain
Do you anticipate that your pet will need some type of travel-anxiety medicine prescribed?
*
(select one)
Yes
No
Do you anticipate that your pet will be traveling as an emotional support pet?
*
(select one)
Yes
No
Have you traveled with this pet in this capacity prior?
*
(select one)
Yes
No
Do you have official documentation from a physician to support this?
*
(select one)
Yes
No
Is your pet traveling with you, alone, or with someone else?
*
(select one)
with me
with someone else
alone (being picked up by someone else)
Please provide contact information of person traveling with or picking up your pet at destination
*
Phone of contact person
*
Email of contact person
*
Address line 1 for contact person
*
Address line 2 for contact person
*
Dr. Janis Shinkawa
Dr. Jill Muraoka Lim
Dr. Nicci Quinn
Dr. Donnalee Dorman
Dr. Megan Glaser
Dr. Amy Vlazny
Dr. Lisa Kentfield
Dr. Marnie Burgoyne
Dr. McKenzie Rasmussen
Dr. Karalyn Kane
Dr. Steffani Klittich
Dr. Jon Dickson
Dr. Allie Jones
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