Balanced Paws Veterinary Rehabilitation
Euthanasia Request
New Patient Information
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pet's Name
*
Breed
*
Age/DOB
*
Male/Female
*
Spayed/Neutered
*
Approximate Weight (lbs)
*
Who is your primary veterinarian/ clinic ?
*
What is the reason youre saying goodbye to your pet?
*
What days work best for you?
*
Tuesday
Wednesday
Thursday
Friday
What time of day works best for you?
*
Morning
Afternoon
Evenings
What kind of aftercare would you like for your pet?
*
Take them home
Individual Cremation ( recive ashes back)
Communal Cremation ( do not receive ashes back)
Would you like a clay paw print and ink prints? ( additional $30 )
*
Yes, Please
No, Thank you
Would you like to be present?
Yes
No
Unsure
Any additional information you would like us to know or any questions?
Submit
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