Customer Information Form

Owner/Agent*

First NameLast Name
Secondary Owner Name

First NameLast Name
Email
VET EMAIL
Owner/Agent Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Phone type*

CellHome
I consent to having a Peaceful Passing Veterinarian contact me by text message prior to their arrival:

yesno
Address*

Street Address

Street Address Line 2

City Province

PostalCountry
Parking Instructions*
ex. If driveway parking is not possible, please give alternative such as street parking only, underground parking garage, visitor parking, etc...
Apartment Buzzer Number
Urgency of appointment*

TodayTomorrowThis weekNext weekThis monthMonth+
Patient details:
Pet Name*
Age:*
Sex*

Male IntactMale NeuteredFemale IntactFemale Spayed
Species*

CanineFelineOther
Indicate Other Species
ex. Bunny
Weight*
in pounds
Breed*
Colour*
My beloved pet has passed away at home from natural causes and I am looking for assistance with transportation and cremation.

YesNo
Please describe your pet's health concerns and any relevant medication*
Did your pet pass from a known infectious disease?

YesNo
Please Provide details of infectious disease
Date of Your Pet's Passing

MonthDayYear
Date
Current Veterinary Clinic*
Vet Clinic Email
example@example.com
Do you consent to Peaceful Passing requesting relevant medical history from your pet's regular clinic?*
Please comment on your pet's temperament for vet visits, medical procedures, and also your pet's response to new visitors in your home*
ex. calm / nervous / aggressive
Does your pet have the tendency to bite or scratch when stressed?*

YesNo
Has your pet bitten anyone in the past 10 days? There is a 10 day waiting period before a pet who has bitten may be euthanized.*

YesNo
Aftercare *
Would you be interested in purchasing an Urn or Paw Print?*

YesNoMaybe
Scheduled Appointment Date & Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Attending Veterinarian
Payment Method
Confirmed Aftercare Selection

Private CremationCommunal CremationBurialPrivate AquamationOther arrangement by owner
Delivery Option
Note for Veterinarian
Confirmed Gateway Memorial Products

Upgraded Urn already arranged and paidPaw print already arranged and paidKeepsake(s) already arranged and paidSilk PouchScatter tubeDecline Upgraded UrnDecline paw print and keepsake(s)Lasting MemoriesBurial/Other Arrangement- None
Confirmed Aquamation Memorial Products

Cotton bag3D printed biodegradable grey scatter tubeHair clippingInk paw printInk nose printAccess to pet parent portal
Paw Print Item Number
Urn Item Number
Keepsake(s) Item Number
QB Shorthand

K9FELINEHCSEDK9SEDK9LSEDK9XLCCK9CCK9LCCK9XLPCK9PCK9LPCK9XLSEDFCCFPCFXMLGAHNPCVQOLIHQOL
XMLG
Total XMLG cost $
Veterinary Consultation

YesNo
Type of Consultation
Invoice Amount
Interac
UTM Source
UTM Medium
UTM Campaign
UTM Content
Submission Page
UTM Term
How did you hear about PeacefulPassing?

Search Engine (Google, Bing etc.)Social Media (Facebook, Instagram)Recommendation from friend/familyRecommendation from my vet clinicI am a previous clientGuelph TodayOther
Between 8am and 8pm, upon submission of this form, you should receive your personalized information and quote within approximately 30 minutes. If you have not received it within an hour please check your SPAM/JUNK folder or notify us at info@peacefulpassing.ca. PLEASE NOTE THAT WE ARE NOT AVAILABLE OVERNIGHT.
Should be Empty:

Patient details: