Customer Information Form

Owner/Agent*

First NameLast Name
Secondary Owner Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Phone type*

CellHome
I consent to having Peaceful Passing contact me by text message

yesno
Address*

Street Address

Street Address Line 2

City Province

PostalCountry
Parking Instructions
ex. Underground parking garage, behind red car
Apartment Buzzer Number
Urgency of appointment*

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

Male IntactMale NeuteredFemale IntactFemale Spayed
Species*

CanineFelineOther
Indicate species
Weight*
in pounds
Breed*
Colour*
Please describe your pet's health concerns and any relevant medication
Current Veterinary Clinic*
Temperament for vet visit*
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
Burial
Private Cremation
Communal Cremation
Appointment Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Veterinarian
Veterinarian Email
example@example.com
Payment Method
Etransfer password
Note for Veterinarian
Customer Selection

Private CremationCommunal CremationBurialOther arrangement by owner
Memorial Products

Upgraded Urn already arranged and paidComplimentary Scattering Tube, no paw printPaw print already arranged and paidComplimentary Silk Pouch, no paw printDecline paw printOwner wants 48 hrs of Lasting Memories Access for urn/paw print
QB Shorthand

K9FELINEHCQOLVQOLPVPSEDRSEDLSEDXLSEDBCCCPXMLGAHDOA PUDOA DO
XMLG
Consultation

YesNo
Invoice Amount
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 clientOther
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: