Pets to Rest - Registration Form

Pets to Rest - Registration Form

Please know, your information is confidential. For additional information please see our website link at the bottom of this form (petstorest.ca).
Owner Information
Primary owner*

First NameLast Name
Main phone*
Please enter a valid phone number.
Alternate phone
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Buzzer code / parking instructions if applicable
Secondary owner / authorized agent (if applicable)

First NameLast Name
Address (if different from primary owner)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Do we have your permission to securely transmit confidential information over email after you submit this form?*

Yes
Patient / Animal Information
Pet's name*
Species*
Age or date of birth*
Breed*
Sex*
Approximate weight (lbs)*
Colour*
Microchip / tattoo (if applicable)
Regular veterinary clinic*
Appointment time frame*
Current health condition(s) and concerns*

0/300
What is the temperament of your pet with visitors to the home?*
Has your pet previously needed oral sedation for vet visits? If so, or if you feel it may help create a more comfortable experience, please consult your regular veterinarian (we are unable to prescribe this prior to our appointment).*
Has this pet bitten any person in the last 10 days? (Public Health requires a 10 day Rabies quarantine prior to euthanasia in most cases)*
Aftercare & Memorialization Wishes
Please see Gateway's catalogue for clay paw print and memorialization options here
Aftercare Wishes*
Would you like a free ink paw print?
To be mailed or taken at your home if making your own aftercare arrangements
Do you wish to purchase a clay paw print, please specify:
If you choose a Lasting Paw print, please specify name as you wish it to appear (12 characters limit):
If you choose a Precious Paw print, please specify name as you wish it to appear (15 characters limit):
How memorialization items and the ashes, if applicable, will be returned to you:
For Private Cremation Only

Complimentary urns and alternative choices from Gateway Pet Memorial
Complimentary Urn Option
If you chose a wood or metal urn, what name would you like engraved (complimentary)?
I choose an alternative urn option from the Gateway Pet Memorial site:
Please contact Pets to Rest for pricing information
I choose engraving for the selected alternative urn:
Note limitations depending on chosen item
Did We Miss Anything?
Please let us know if you have any questions, concerns or requests that were not already addressed?
Please verify that you are human*
London In-Home Pet Euthanasia Website: petstorest.ca
Should be Empty:

Pets to Rest - Registration Form

Owner Information

Patient / Animal Information

Aftercare & Memorialization Wishes

For Private Cremation Only

Did We Miss Anything?