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UPC Omaha - Euthanasia Form
1
Which location will you be visiting?
Papillion Office, 8455 South 73rd Plaza, Papillion, Nebraska
Millard Office, 4257 South 144th Street Omaha, Nebraska
Papillion Office, 8455 South 73rd Plaza, Papillion, Nebraska
Millard Office, 4257 South 144th Street Omaha, Nebraska
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First Name
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Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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4
Family Veterinary Clinic
Patient Name
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5
Type of Pet
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Cat
Dog
Reptile
Bird
Pocket Pet
Other
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6
If other, please specify
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7
Breed
Color
Age or Birthdate
Male
Female
Unknown
Male
Female
Unknown
Male or Female
Spayed
Neutered
Not Altered
Spayed
Neutered
Not Altered
Spayed or Neutered
Yes
No
Unsure
Yes
No
Unsure
Current on all Vaccinations
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8
Reason for Euthanasia
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I understand and hereby certify that I am the owner (or duly authorized agent for the owner), that I do hereby give Urgent Pet Care authorization to euthanize the said animal in whatever manner the DVM shall deem fit. I do hereby, and by these present forever release the DVM & UPC from any liability for so euthanizing the said animal. I do also certify that the said animal has not bitten any person or animal during the last fifteen (15) days, and to the best of my knowledge has not been exposed to Rabies. Please respond with your full name to use as your signature.
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Clear
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10
What type of Aftercare Wishes would I like to use for my Pet.
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Private Cremation - Ashes will be returned to me. I wish to have my pet individually cremated offsite at Paws & Remember. Prices start at $130.00 for cats and dogs, and $71.00 for Exotic Pets, depending on the weight of the pet and which urn package is selected.
Communal Cremation - Ashes will NOT be returned to me. I wish to have my pet cremated communally and understand that the ashes will NOT be returned to me. Price - $45.00
Home Burial - I wish to take my pet home with me for burial, or to make other disposition arrangements.
On Hold - I wish for Urgent Pet Care to hold my pet and I agree to pay a nonrefundable deposit of $45.00 for the cost of a Communal Cremation, if I do not contact Urgent Pet Care about my final wishes. I understand that I have 72 hours to contact Urgent Pet Care regarding my changes to my final wishes or my pet will be sent out for a Communal Cremation and my pet will not be returned to me.
I would like to get more information about other Cremation Services that are available to me.
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Please select one. If you are choosing to have a Private Cremation (see the pictures below)
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I would like a Communal Cremation and not get my pet's ashes returned.
I would like to use a different Cremation Service.
Standard Urn Box
Scattering Bag
PR55 - Contemporary Pet Urn
PR57 - Ebony Pet Urn
PR56 - Classic Pet Urn
PR88 - Vertical Pet Photo Frame Urn
PR13 - Paw Print Memory Box Urn
Other
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12
If other, please specify
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Standard Box Urn - This is one of the options that is included with the private cremation for no extra cost. Your pet's name can be added to the top of the box with Vinyl Lettering at no extra cost, or Engraved into the wood for an extra $15.00.
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Scattering Bag - This is the second option that can be included with the Private Cremation with no extra cost.
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PR55 - Contemporary Pet Urn: You can add this Urn to take you pet home in for an extra $85.00 added to your Private Cremation Price of $130.00 and up depending on the weight of your pet.
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PR57 - Ebony Pet Urn: You can add this Urn to take you pet home in for an extra $60.00 added to your Private Cremation Price of $130.00 and up depending on the weight of your pet.
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PR56 - Classic Pet Urn: You can add this Urn to take you pet home in for an extra $95.00 added to your Private Cremation Price of $130.00 and up depending on the weight of your pet.
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PR88 - Vertical Pet Photo Frame Urn: You can add this Urn to take you pet home in for an extra $80.00 added to your Private Cremation Price of $130.00 and up depending on the weight of your pet.
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PR13 - Paw Print Memory Box Urn: You can add this Urn to take you pet home in for an extra $95.00 added to your Private Cremation Price of $130.00 and up depending on the weight of your pet.
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I would like a different Pet Urn that I chose from Paws and Remembers Website. (Please explain the urn below)
https://www.pawsandremembershop.com/pet-urns/
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21
You must call us to set an appointment
Call Papillion Office
Call Millard Office
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