North Madison Veterinary Clinic Pet Cremation Information and Payment Form

Pet Cremation Information and Payment Form

In order for cremation to take place, our policy is for this form to be completed and payment submitted prior to cremation. All fields with a RED * must be filled in to continue to the payment screen.
For assistance with this form, please call our office at (812) 273-5737
Pet Owner Information
Name of Pet Owner*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Name of Person at Alternate Phone Number

First NameLast Name
Email*
example@example.com
Pet Information
Name of Pet*
Animal Species*
Other Species Type
List species if not a cat or dog (i.e. rabbit, chicken, etc.)
Date of Birth or Appoximate Age*
Animal Breed
Approximate Weight*
If pet is over 125# please call the office to discuss arrangements prior to form sumission
Gender*
Color and Markings
Date of Death*

MonthDayYear
Are there any belongings to be cremated with your pet? (i.e. - blanket, toy, etc.)*
Description of items to be cremated. Unless items are listed specifically below, they will be disposed of accordingly.
Any additional items sent with the pet and not listed above will be disposed of accordingly
Cremation Selections and Payment
All urns are milled from local lumber and are hand crafted for each pet. They are natural color, sealed, and created by a local craftsman.
Please upload a maximum of 2 pictures to be used for the urn selected above.

Click browse files to upload
Cancelof
Please enter the text you would like exactly as you would like it to appear on the urn. Two lines of text are available with approximately 35 characters max per line. Please make sure all spelling, capitalization, punctuation, and date formats are identical to the way you want them to appear on the name plate.

For Example:

Abby - "My baby girl"

08/01/2001 - 11/16/2017
Line 1
Line 2
You may drop-off your pet at our location or we can pick-up your pet at your local primary care veterinarian.

Drop off at our facility is

Monday through Friday

8:00am to 5:00pm

North Madison Veterinary Clinic

1848 E 400 N

Madison, IN 47250
Location of Pet to pick-up for cremation*
My Products*
prevnext( X )
Private Cremation - Cardboard BoxYour pet's remains will be returned in a cardboard box.
$190.00 Fur clipping



Private Cremation - Wooden Urn. Pet is less than 125 lbs.Your pet's remains will be returned in a wood urn of your wood choice. You may add up to two 4" x 6" pictures to the urn. If two pictures are selected, they should be the same orientation. Pictures must be submitted with this form so the urn can be made to fit the pictures. You may add a metal name plate and fur clipping at no additional charge.
$290.00 Wood ChoicePicturesName PlateFur clipping



Private Cremation - Wooden Urn. Pet is more than 125 lbs. 2Your pet's remains will be returned in a wood urn of your wood choice. You may add up to two 4" x 6" pictures to the urn. If two pictures are selected, they should be the same orientation. Pictures must be submitted with this form so the urn can be made to fit the pictures. You may add a metal name plate and fur clipping at no additional charge.
$305.00 Wood ChoicePicturesName PlateFur clipping



Paw PrintKeepsake paw print in a shadowbox frame with the Rainbow Bridge poem on the adjacent cover. Faux leather case. (We do our best on the paw print, but every situation varies to the way the print turns out.)
$35.00 Quantity
Item subtotal:$0.00



Total

$0.00
Cremation Authorization

I am authorizing North Madison Veterinary Clinic to cremate the pet listed above. I have read and understand this form.

I understand there may be additional charges and arrangements if my pet is over 125 lbs.

Cremation will take place once this autorization form is completed, signed and payment is received. Because of the handcrafted nature of the urns, please allow 7 to 14 days for completion of products and services requested above.

Following the cremation, you will be contacted by your local primary care veterinarian or the North Madison Veterinary Clinic when your pets cremated remains are ready to be picked up.

I represent that, to the best of my knowledge, the animal has not bitten any person or other animal during the past 10 days, was not suffering from Rabies, and has not been exposed to other animals suffering from Rabies.
Signature*

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Date*

MonthDayYear

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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Pet Cremation Information and Payment Form

For assistance with this form, please call our office at (812) 273-5737

Pet Owner Information

Pet Information

Cremation Selections and Payment

Cremation Authorization