Health Certificate Form - Rogue Equine & Companion Animal Clinic

Health Certificate Form - Equine

This completed form is required by law in order for us to provide service. This information is kept secure, private and will not be shared with any 3rd party without your expressed consent. Please use "Coggins and Health Certificate Form" if a Coggins/EIA test is required to be run.

An EIA/Coggins test has been pulled/run and is valid for the State of destination.*
- Yes
- No. Do not complete this form. Please complete the Coggins and Health Certificate Form .
An EIA/Coggins test was run by Rogue Equine Hospital*
- Yes
- No. Please scan and send a legible test copy by email to equine-forms@rveh.com. No further action can be taken without this documentation.
Purpose for a Health Certificate*
Agent Information
Are you an agent or representative of the owner?*
- Yes
- No
If you indicate yes, please complete the following sections. Otherwise please skip to the owner section.
Agent Name
First Last
Agent Mobile Number
Agent Email Address
Who do we communicate with?
- Agent
- Owner
Owner Information/Consignor
Owner/Consigner Name*
First Last
Owner/Consignor Mailing Address (if different, otherwise leave blank)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Owner/Consignor Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Owner/Consignor Mobile Phone Number*
Owner/Consignor Email*
Horse Information
Horse Name*
Horse Name
Breed (please fill in)*
Color*
Markings*

Examples include star, right hind sock, left hind pastern (white), brand description, etc.
Sex (please choose one)*
Horse Date of Birth*
MM slash DD slash YYYY
Additional horses to list - optional
Name Breed Sex Age Color Markings
Address of where horse(s) reside, if different than your physical address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Destination Information for Health Certificate or "CVI"
Date of Departure for Destination*
MM slash DD slash YYYY
Name of person hauling/transporting, or company name.*
First Last or company name
Please list yourself if you are hauling.
Name of person/Consignee receiving if different from owner.
First Last
Phone number of person/Consignee receiving if different from owner
Address of Destination/Consignee*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Must have physical address. If show grounds, the city, state and name of show grounds is adequate.
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Email
This field is for validation purposes and should be left unchanged.

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serving Southern Oregon and Northern California.

Health Certificate Form - Equine

Agent Information

Owner Information/Consignor

Horse Information

Destination Information for Health Certificate or "CVI"

Services

Preventive Care

Complementary Medicine

Portals

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Information

Hours & Info

Name	Breed	Sex	Age	Color	Markings