Health Certificate Request

Owner
Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email*
Origin
Name of Barn or Farm Origin*
Address*
Street Address City State ZIP Code
Phone
Date Leaving*
Hauler
Hauler Information*
Name
First Last
Address
Street Address City State ZIP Code
Hauler Phone Number
Destination
Please visit the Department of Agriculture to view individual state requirements for legal entry and interstate travel. You may click here or call our office to request information regarding international travel.
Add Additional Destinations
- 1st Destination
- 2nd Destination
Name of Destination or Contact*
Address*
Street Address City State ZIP Code
Purpose of the trip
Phone
Name of Destination or Contact*
Address*
Street Address City State ZIP Code
Purpose of the trip
Phone
Horse
Please note that all horses must be listed separately on the Health Certificate with the exception of foals under the age of 6 months that have not yet been weaned; such foals can be listed as "foal by side" and consequently do not require their own coggins test.
Number Of Horses
- 1 Horse
- 2 Horses
- 3 Horses
- 4 Horses
- 5 Horses
1. Horse Barn/Registered Name
Has this horse been seen by Mid-Rivers Equine Centre within the past 30 days?
Age*
Age Cont.
Breed
Color
Sex
Coggins Location*
Please note that all horses must have a valid EIA or Coggins test for legal interstate travel, please visit the Department of Agriculture to view individual state requirements.
Horse Accession Number
Lab Name
Lab Address
City State
Date of Blood Draw
Test Result
Type of Test
Date Reported
Registration #
Electronic ID #
2. Horse Barn/Registered Name
Has this horse been seen by Mid-Rivers Equine Centre within the past 30 days?
Age*
Age Cont.
Breed
Color
Sex
Horse Coggins Location*
Horse Accession Number
Lab Name
Lab Address
City State
Date of Blood Draw
Test Result
Type of Test
Date Reported
Registration #
Electronic ID #
3. Horse Barn/Registered Name
Has this horse been seen by Mid-Rivers Equine Centre within the past 30 days?
Age*
Age Cont.
Breed
Color
Sex
Horse Coggins Location*
Horse Accession Number
Lab Name
Lab Address
City State
Test Result
Type of Test
Registration #
Electronic ID #
4. Horse Barn/Registered Name
Has this horse been seen by Mid-Rivers Equine Centre within the past 30 days?
Age*
Age Cont.
Breed
Color
Sex
Date of Blood Draw
Date Reported
Horse Coggins Location*
Horse Accession Number
Lab Name
Lab Address
City State
Date of Blood Draw
Test Result
Type of Test
Date Reported
Registration #
Electronic ID #
5. Horse Barn/Registered Name
Has this horse been seen by Mid-Rivers Equine Centre within the past 30 days?
Age*
Age Cont.
Breed
Color
Sex
Horse Coggins Location*
Horse Accession Number
Lab Name
Lab Address
City State
Date of Blood Draw
Test Result
Type of Test
Date Reported
Registration #
Electronic ID #
Medical History
Vaccination History (for each horse listed)
Prior Destination(s) in the Past 30 Days (for each horse listed)
Please note that we cannot complete a Health Certificate without all of the required information as it pertains to each destination.
I understand this is a REQUEST FOR HEALTH CERTIFICATE ONLY.*
- Yes
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Health Certificate Request

Owner

Origin

Hauler

Destination

Horse

Medical History

Services

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