Client Registration Form
How did you hear about us?
Have you used our services before?
Yes
No
Please indicate the type of service you are looking for below.
In-Home Euthanasia
Hospice and Palliative Care Consultation
Quailty of Life Assessment
Date you would like to book appointment?
-
Month
-
Day
Year
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?
*
Morning
Afternoon
Evening
No preference
Name of pet's primary owner?
*
First Name
Last Name
Name of pet's secondary owner? (if applicable, and their relationship to you)
First Name
Last 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
*
Please Select
Ontario
Saskatchewan
British Columbia
Manitoba
Alberta
New Brunswick
Nova Scotia
Prince Edward Island
Newfoundland and Labrador
Quebec
Northwest Territories
Nunavut
Yukon
Postal Code
*
Is there parking available for the veterinarian at your address? Is there any information our team should know in order to gain access to your home? (buzz number, side door, hidden drive way etc.)
*
Your E-mail
*
example@example.com
Home Phone Number
*
Cell Phone Number
Work Phone Number
Please list any 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?
*
Dog
Cat
Rabbit
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
*
Male
Female
Neutered/Spayed
*
Neutered
Spayed
Intact
Pet's weight
*
Please indicate kg or lb
What are your aftercare wishes should your pet be euthanized?
*
Private Cremation with Ash Return
Semi Private Cremation with Ash Return
Communal Cremation without Ash Return
Home Burial
Undecided
Storage (The crematory we work with, Eternal Companions, offers to keep pets safely in their care for families who wish bury their pet at home, but are prevented from doing so due to winter conditions. They will keep your pet at their facility in cold storage until you are able to proceed with a burial)
Burial with Eternal Companions
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 when going to the vet? We want to be as prepared as possible to ensure the appointment goes smoothly and peacefully for your pet.
*
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.
*
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