Form Health certificate

Breeder data:

Full name: _____________________________ _____________________________ ______________________________

Address: __________________________________________________________________________________________

Animal data:

Surname in metrics: _______________________________ Breed: _______________________________

Date of birth: __/__/20__yr.

Sex:

□ Male □ Female

Tattoo/Microchip: _______________________________

1	Body temperature	_______________ °С
2	Skin	□ Clean □ Ectoparasites □ Lesions
3	Ears	□ Normal □ Contaminated □ Lit
4	Eyes (Eyelids)	□ Normal □ Entropy □ Lit
5	Nasal mucosa	□ Normal □ Selection □ Lit
6	Teeth (Bite)	□ Correct □ Underbite □ Snack
7	Knee (Patella)	□ Normal □ Luxation
8	Joint (Elbow, Hip)	□ Normal □ Deviations
9	Testis (Male)	□ Normal □ Cryptorchidism
10	Weight	_______________ grams
11	Heart	□ Normal □ Violations
12	Umbilical hernia	□ Yes □ No □ Deleted
13	Inguinal hernia	□ Yes □ No □ Deleted
14	Deworming	__/__/20__yr.
15	Ectoparasites processing	__/__/20__yr.
16	Other marks

Medical opinion:

I, __________________________________________________________ perform my work within the veterinary clinic,

(Name of the veterinarian who performed the examination)

______________________________________________, located at ___________________________________________

(name of the veterinary clinic) (address at which the veterinary clinic is located)

This affidavit confirms that the above-described animal was examined by me today and that all the mentioned necessary examinations to certify the state of health of the animal were carried out. In conclusion, the animal was recognized as healthy for any infectious diseases, and it was also confirmed that the specified animal is in good condition and suitable for transportation.

Contacts of the parties:

Name of veterinarian: ______________________________ Person who applied: ____________________

Veterinary clinic: _________________________________ Telephone number of the person: ___________________

Address of the clinic: ______________________________

Phone number of the clinic: _________________________

_______________ _______________

(signature) (signature)