Euthanasia Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet Name
*
Species
*
Please Select
Canine
Feline
Breed
*
Age
*
Weight
*
Sex
*
Please Select
Male
Female
Veterinary Clinic Name
Medical History/Current Conditions ( please list all)
Reason For Euthanasia
*
Preferred Date Of Service
*
-
Month
-
Day
Year
Date
Preferred Time
*
Please Select
Morning
Afternoon
Evening
Aftercare
*
Private Cremation- your pet will be cremated individually and his/her ashes will be returned to you in 2-3 weeks.
Communal Cremation- your pet will be cremated and ashes will not be returned
I will not need cremation services and will arrange my own aftercare. Pet will remain in home after the procedure ( local laws apply)
Ashes Delivery
Home Delivery ( 50$)
Pick Up at Crematory ( West Babylon)
Does Not Apply
Paw Print
*
Clay (40$)
Ink Paw (20$)
Ink Nose Print (20$)
None
Number of Family Members Present
*
How Did You Hear About Us ?
Please Select
Google
VetAngel
Word of Mouth
Other
Other Pets in Homes
*
Please Select
Yes
No
Date/Time ( will do best to accommodate)
I confirm that I am the owner of the pet named above and authorize Dr. Fasano to perform euthanasia. I understand that euthanasia cannot be reversed. I understand that payment is due at time of service. By signing below, I confirm that I understand and agree to the above.
*
Continue
Continue
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