Health Certificate Request

Download Form

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*
MM slash DD slash YYYY
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
On what date did a Mid-Rivers veterinarian last see this horse?
MM slash DD slash YYYY
Age*
Age Cont.
Breed
Color
Sex
Coggins Location*
Please note that all horses must have a valid negative EIA or Coggins test for legal interstate travel, please visit the Department of Agriculture to view individual state requirements.
Upload Negative Coggins Test
Max. file size: 50 MB.
2. Horse Barn/Registered Name
On what date did a Mid-Rivers veterinarian last see this horse?
MM slash DD slash YYYY
Age*
Age Cont.
Breed
Color
Sex
Horse Coggins Location*
Upload Negative Coggins Test
Max. file size: 50 MB.
3. Horse Barn/Registered Name
On what date did a Mid-Rivers veterinarian last see this horse?
MM slash DD slash YYYY
Age*
Age Cont.
Breed
Color
Sex
Horse Coggins Location*
Upload Negative Coggins Test
Max. file size: 50 MB.
4. Horse Barn/Registered Name
On what date did a Mid-Rivers veterinarian last see this horse?
MM slash DD slash YYYY
Age*
Age Cont.
Breed
Color
Sex
Date of Blood Draw
MM slash DD slash YYYY
Date Reported
MM slash DD slash YYYY
Horse Coggins Location*
Upload Negative Coggins Test
Max. file size: 50 MB.
5. Horse Barn/Registered Name
On what date did a Mid-Rivers veterinarian last see this horse?
MM slash DD slash YYYY
Age*
Age Cont.
Breed
Color
Sex
Horse Coggins Location*
Upload Negative Coggins Test
Max. file size: 50 MB.
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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