Questions about Services Form

This form is for families who have questions about our services, but are not ready to schedule an appointment. Please fill out the following information.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Name of your pet*
What type of pet do you have?*

DogCatOther
What is the gender of your pet?*

MaleFemale
What is your pet's approximate weight?*
If your pet is a specific breed, please list here.
What is your pet's approximate age?
Please let us know the main symptoms or disease(s) for your pet. (i.e. kidney failure, mobility issues, dementia, cancer- what type our source).
Please let us know what questions you have for us. Please note that our website has most information listed about cost, travel fees, service areas, and flow of the home visit. *
Which of our services are you interested in?*

Home euthanasia only, no aftercare will be neededHome euthanasia with communal cremation, no ashes returnedHome euthanasia with private cremation, ashes returned
Thank you for your inquiry. Dr. Henderson or Dr. Heinemann will contact you at the phone number provided when she is safely able to between home visits and driving. Initial contact may be a text message. If received after business hours, she will reply the following morning.
Should be Empty:

This form is for families who have questions about our services, but are not ready to schedule an appointment. Please fill out the following information.