Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
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State
Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
*An Additional travel fee may apply based on our service map.
Preferred Method of Contact
Text
Phone Call
Email
Any other request or information to add for at-home euthanasia? Gate codes, directions, etc.
What day and time would you prefer us to come to your home? All regular appointment times are during business hours: Monday-Friday 10am-6pm, and Saturdays from 10am-3pm. Appointments outside of these hours have limited availability. Appointments last up to 2 hours.
*
Morning
Afternoon
Evening
Late Evening (7pm-9:30pm) (Additional fee may apply.)
Your Pet's Name
*
Brief information about the issue(s) your pet is having:
*
Species
*
Cat
Dog
Other
Pet's Gender
*
Male
Female
Pet's Age
Your Pet's Estimated Weight (in Pounds) for Dosing Medications *Important*
*
What are you wishes for aftercare and/or keepsakes?
*
Private Cremation (Includes standard urn options, paw print, certificate of authenticity, and hand delivery of all keepsakes. Additional keepsakes available for order.)
Communal Cremation (No ashes returned.)
Communal Cremation (Additional keepsakes available for direct customer order.)
Home Burial (Please check all local and county regulations.)
Other
Would you like us to notify your primary care veterinarian?
Yes
No
If yes, who is your primary care veterinarian?
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