Customer Information Form

We are so sorry for your loss.

This form is meant for pet-owners whose beloved pet has passed away at home and are looking for assistance with transportation and aftercare (cremation). We are here to help. After you have filled out this form, our client care team will be in touch right away with more information, pricing, and to arrange for a team member to visit your home. You and your pet are in good hands.
My beloved pet has passed away at home and I require assistance with transportation and cremation arrangements.

YesNo
We believe you may be looking for our in-home euthanasia and aftercare services for your beloved pet. Please do not continue to fill out this form and instead, click on the link below, to fill in the proper patient intake form.

Patient intake form

We are thinking of you at this challenging time,

The Peaceful Passing Team
Date and Approximate Time of Your Pet's Passing*

MonthDayYear
Date
Hour MinutesAM/PM Option
Owner/Agent*

First NameLast Name
Secondary Owner Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Phone type*

CellHome
I consent to having client care contact me by text message

yesno
Address*

Street Address

Street Address Line 2

City Province

PostalCountry
Parking Instructions
ex. Underground parking garage, behind red car
Apartment Buzzer Number
Beloved pet details:
Pet Name*
Age:*
Sex*

Male IntactMale NeuteredFemale IntactFemale Spayed
Species*

CanineFelineOther
Indicate species
Weight*
in pounds
Breed*
Colour*
Current Veterinary Clinic*
Vet Clinic Email
example@example.com
Did your pet pass from a known infectious disease? If so, please provide details:*
Aftercare *
Delivery Option
Would you be interested in purchasing an upgraded urn, paw print, or other keepsake item?*

YesNoMaybe
Appointment Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Staff Member (porter)
Staff Email Address
example@example.com
Payment Method
Etransfer
Confirmed Aftercare Selection

Communal CremationPrivate CremationPrivate Aquamation
Confirmed Gateway Memorial Products

Upgraded Urn already arranged and paidPaw print already arranged and paidKeepsake(s) already arranged and paidSilk PouchScatter tubeDecline Upgraded UrnDecline paw print and keepsake(s)Lasting MemoriesBurial/Other Arrangement- None
Confirmed Aquamation Products

Cotton bag3D printed biodegradable grey scatter tubeHair clippingInk paw printInk nose printAccess to pet parent portalDecline Upgraded UrnDecline paw print and keepsake(s)Lasting MemoriesBurial/Other Arrangement- None
Aquamation Delivery Options

Deliver to regular clinicPick up directly from Reflections in KitchenerOther (please specify)
Paw Print Item Number
Urn Item Number
Keepsake(s) item number(s)
Notes for Staff Member
QB Shorthand

K9K9LK9XLFELINEHCPCCCXMLGAH
Invoice Amount
How did you hear about PeacefulPassing?

Search Engine (Google, Bing etc.)Social Media (Facebook, Instagram)Recommendation from friend/familyRecommendation from my vet clinicI am a previous clientOther
Between 8am and 8pm, upon submission of this form, you should receive your personalized information and quote within approximately 30 minutes. If you have not received it within an hour please check your SPAM/JUNK folder or notify us at info@peacefulpassing.ca. PLEASE NOTE THAT WE ARE NOT AVAILABLE OVERNIGHT.
Should be Empty:

We are so sorry for your loss.

Beloved pet details: