Euthanasia Request Form

First Name*

Last Name*

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Email*

Phone*

Pet's Name*

Breed*

Male / Female*

Spayed / Neutered*

Age / DOB*

Approximate Weight (lbs)*

Who is your primary veterinarian/ clinic ?*

What is the reason you're saying goodbye to your pet?*

What days work best for you?*

Tuesday

Wednesday

Thursday

Friday

What time of day works best for you?*

Morning

Afternoon

Evenings

What kind of aftercare would you like for your pet?*

Take them home

Individual cremation (receive ashes back)

Communal cremation (do not receive ashes back)

Would you like a clay paw print and ink prints? (additional $30)*

Yes, please

No, thank you

Would you like to be present?*

Yes

No

Unsure

Any additional information you would like us to know or any questions?

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