Client Registration Form

Client Registration Form
How did you hear about us?
Have you used our services before?

YesNo
Please indicate the type of service you are looking for below.

In-Home EuthanasiaHospice and Palliative Care ConsultationQuality of Life Assessment
Date you would like to book appointment.

MonthDayYear
If you don't want to book something right now, but would prefer for us to have your information in our system for when you do want to book, you can leave this section blank.
Preferred time of day.*

MorningAfternoonEveningNo preference
Name of pet's primary owner.*

First NameLast Name
Name of pet's secondary owner (if applicable, and their relationship to you).

First NameLast Name and Relationship
Are there any other family members or friends who play a significant role in your pets life? If so, please list their names and their relationship to you.
Please include relationships to primary owner.
Children's ages (if applicable).
Do you have additional pets in your household? If so, please provide their names and species.
Home Address*
City/Area*
Province*
Postal Code*
Your E-mail*
example@example.com
Home Phone Number*
Cell Phone Number
Work Phone Number
Please list any and all veterinary clinic(s), or emergency and specialty hospital(s) that your pet has been to in the last three years.*
If you have pet insurance, please give the name of your provider. If not, leave blank.
Pet's Name*
Is your pet a dog, a cat, or a rabbit?*

DogCatRabbit
Pet's Breed*
(example: German Shepherd, Domestic Shorthair, Cornish Rex etc.)
Pet's Colour*
(example: Orange Tabby, Black & Tan, Blue Merle, Calico etc.)
Pet's Age*
Sex*

MaleFemale
Neutered/Spayed*

Neutered/SpayedIntact
Pet's weight*
Please indicate kg or lb
Please tell us more about what is happening with your pet and list any known medical conditions as well as current symptoms that your pet is experiencing.*

Please include at least fifty words.0/0
Aftercare For Your Pet
What are your aftercare wishes should your pet be euthanized?*

Private Cremation with Ashes ReturnedSemi Private Cremation with Ashes ReturnedCommunal Cremation with No Ashes ReturnedHome BurialUndecided
How does your pet do with getting needles, during visits to the vet and/or having strangers in the home? Are they nervous or anxious, or ever require medication for anxiety or when going to the vet? We want to be as prepared as possible to ensure the appointment goes smoothly and peacefully for your pet. *
Is there parking available for the veterinarian at your address?

DrivewayStreet ParkingVisitor Parking
Is there any information our team should know in order to gain access to your home? (buzz number, side door, hidden drive way etc.)*
If you'd like, you can upload a picture of your pet here.

Please upload picture in .jpg, .jpeg, or .png format.
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After your form is submitted, it will be delivered to our representatives, and they will respond to you via email as soon as possible.
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Client Registration Form

Aftercare For Your Pet

After your form is submitted, it will be delivered to our representatives, and they will respond to you via email as soon as possible.