Peaceful Paws
Clarion
Pet Parent’s Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pet’s Name
*
Species
*
Cat
Dog
Breed
*
Age
*
Estimated Weight
*
I’m concerned my pet may be particularly anxious, nervous or aggressive
*
Yes
No
Please briefly indicate your pet’s symptoms or diagnosis, reason that in-home end of life care is requested.
*
Pet’s current veterinarian (if any)
Please notify my current veterinarian of my pet’s passing
Yes
No
Other pet care teams you’d like to have notified-groomer, kennel etc. (please list phone number)
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Aftercare
Chosen aftercare option:
*
Peaceful Paws will provide transport of my pet to Goble Funeral Home for communal cremation. I WILL NOT receive ashes back.
Peaceful Paws will provide transport of my pet to Goble Funeral Home for private cremation and we, the family, WILL PICK UP the ashes. Special arrangements can be made for personalized urns and memorials directly through Goble Funeral Home at 814-226-7730 if interested.
I will provide for my pet’s aftercare through burial or separate funeral home arrangements.
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Office Use Only
Exam/Treatment/Medications
Follow up sent
Yes
No
Memorial form
Yes
No
Keepsake
Yes
No
Mileage
miles
Payment received (method)
Submit
Should be Empty: