End of Life Care Form

End of Life Care Form

We’re here to help you and your pets through what we know is a difficult and heartbreaking time in your lives.

APPOINTMENT

7

End of Life Care Form

Please complete the form below to request an appointment.

Pet Parent - Please use the same name you use at your vet's office *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Is this a condo/apartment? *

Yes
No

Is this your mailing address?

Yes
No

Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

What other family members will be involved in your pet's appointment?

Instructions: cross streets, house color, cars, etc. that will help us find your home

Phone Number *

Receive texts at above number? *

YES
NO

Email *

Have you used our services before? *

Yes
No

Who is your pet's veterinarian? *

Veterinary Clinic Name *

What dates and times are you considering for your appointment?

Pet Information

Patient Name *

Pet's Date of Birth *

Exact date of birth or estimated date of birth? *

Exact
Estimated

Sex *

Male
Female

Is your pet spayed or neutered? *

Yes
No

Species

Cat
Dog

Breed *

Weight *

Enter weight in pounds.

Color *

Tell us a little about your pet's issue. *

Is your pet currently on any medications and/or supplements (including CBD)? *

Do we have your authorization to post a memorial about your pet? Your pet's first name and an included photo would be the only identifier. *

Yes
No

If you would like, please upload a photo of your pet.

Drag & Drop Files, Choose Files to Upload

How did you hear about us?

If "other," please explain:

If you were referred, please let us know who sent you so we can thank them!

Has your pet bitten (and broken skin) on a person in the last 10 days? *

YES, my pet has bitten.
NO, my pet has not bitten anyone in the last 10 days.

May we help you with aftercare for your pet? *

Communal (no ashes returned to you)
Private (ashes returned)
Home burial/managing my pet’s aftercare. Cremation services are not required

If your pet is 35-90 pounds, do you have one person who can safely help lift your pet on a stretcher? If your pet is over 90 pounds, do you have two people who can safely help lift your pet on a stretcher? (We may be able to provide an extra person with enough notice.) *

Yes
No
My pet weighs less than 35 pounds.