Emergencies
805.658.7387
4547 Telephone Rd., Ste A, Ventura, CA 93003 (
map
)
info@ohanapethospital.com
805.933.1341
957 Faulkner Road, Suite 101, Santa Paula, CA 93060 (
map
)
infosp@ohanapethospital.com
Home
Our Doctors
Dr. Janis Shinkawa
Dr. Jill Muraoka Lim
Dr. Nicci Quinn
Dr. Megan Glaser
Dr. Amy Vlazny
Dr. Marnie Burgoyne
Dr. Steffani Klittich
Dr. Jon Dickson
Dr. Allie Jones
Dr. Helen Smith
Dr. Jessica Kirksey
Dr. Karen Sama
Dr. Cassidy Maugeri
Our Services
Wellness Care
Preventative Care
Pediatric Care
Senior Care
Nutritional Care
Behavioral Care
Holistic Care
Energy Healing
Ohana Rehabilitation Center
End of Life Care
Dental Care
Urgent Care
Pharmaceuticals
VetSource⢠Rx Home Delivery
Surgeries
State of the Art Diagnostics
In the Community
Ohana in the News
Awards
Leave a Review
Contact Us
Emergencies
FAQs
Holiday Schedule
Forms
New Client Form
Traveling with your Pets
Model Release Form
Careers
Associate Veterinarian
Pharmacy Assistant
Registered Veterinary Technicians (RVT)
Veterinary Receptionist
Veterinary Assistant
Shop Online
Menu
Home
»
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
*
Address
Address
Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
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
*
Sex
*
(select one)
Male Neutered
Male Unaltered (not neutered)
Female Spayed
Female Unaltered (not spayed)
Birthdate
*
Is pet microchipped?
*
(select one)
Yes
No
Please provide microchip number
If you do have a microchip, do you have proof of when the microchip was implanted?
(select one)
Yes
No
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)
Adoption
Breeding
Medical Treatment
Owner Relocation
Pleasure
Research
Sale
Show/Exhibition/Sport
Training
Other
Purpose of travel
What is your anticipated departure date?
*
Is it a firm or flexible date?
*
(select one)
Firm
Flexible
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?
*
Destination Address
*
Destination Address
Destination Address
Destination Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
For Hawaii travel only: What is your arrival airport?
Honolulu
Kona
Kahului
Lihue
For Hawaii travel only: What is your arrival program?
Direct Airport Release
5 Day or Less
Subsequent Entry
If your pet is not traveling with you, who will be traveling with or receiving the pet?
Destination Phone Number
*
Destination Email
*
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 reviewed the carrier's pet travel policies?
*
(select one)
Yes
No
Does the airline or carrier (boat, train, etc.) have required supplemental forms that Ohana Pet Hospital will need to complete prior to travel?
*
(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. Megan Glaser
Dr. Amy Vlazny
Dr. Marnie Burgoyne
Dr. Steffani Klittich
Dr. Jon Dickson
Dr. Helen Smith
Dr. Allie Jones
Dr. Jessica Kirksey
Dr. Karen Sama
Dr. Cassidy Maugeri
Logos