In-home Peaceful Transitions
Intake for euthanasia services from Indian River Mobile Veterinary Services
Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Estimates will be sent via email within 24-36 hours of clicking submit (excluding holidays). Please let us know if you would like a phone call, the morning of our next business day(Tuesday/Thursday/Saturday) to answer any questions
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Yes, please call me on your next business day
No, I prefer to communicate via email and will reply
Address
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Street Address
City
Province
Postal Code
Pet's Name
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Sex
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Female
Male
Breed
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Colour/Markings
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Age
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Weight
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Is this request urgent? Please note that only intakes received before 11 am Tuesdays, Thursdays, and Saturdays can be considered for an emergency/same day appointment. We do our best but cannot always accommodate this need
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Yes
No
Why are you considering euthanasia? What’s going on?
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Would you like a Quality of Life Assessment done by the doctor prior to euthanasia? An exam is not mandatory if you are decided, however if Dr. Erwin feels the pet’s presentation doesn’t resemble your description there will be a consultation/examination to determine how to proceed
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Yes
No
Current medication and dosages
Regular Veterinarian/Clinic
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If no current vet please enter " No Vet"
Last Vet Appointment
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If unknown please provide an approximate date
Date of Last Rabies Vaccination
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If unknown please provide an approximate date
Other Vaccine History
Provide Dates and Type of Vaccine received
Is your pet afraid of men?
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Yes
No
Is your pet aggressive?
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Yes
No
Aftercare (visit indianrivermobilevet.com or gatewaypetmemorial.com for a detailed description of cremation options)
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Home Burial (if allowed)
Communal Cremation
Private Cremation
Undecided - We will provide you with costs of both cremation options
Urn selection (for Private cremation only). The following options are complementary with Private cremation
Cedar Memorial Urn
Blue Decorative Metal Urn
Tan Decorative Metal Urn
Carved Wood Urn
Scattering Tube
No Urn/Silk Pouch
Personalization of urn-Name only (optional)
Personalization of urn-Optional additional engraving
Special Urn-see Gateway website for options-please include REFERENCE NUMBER and description
Paw print-please go to gatewaypetmemorial.com for a multitude of choices for this beautiful option for remembering your cherished furry family member. REFERENCE NUMBER and description
Name on paw print (optional)
Additional Memorial options. REFERENCE NUMBER and description
Will you need help moving your pet (for home burial only)?
Yes
No
When are you hoping to proceed? Is there a particular day/time of day you need? Please note that appointments are offered Tuesdays, Thursdays, and Saturdays 11:30-2:30 in 1 hour windows of arrival. Sorry but we cannot accommodate evening appointments.
*
We drive a Honda Fit that doesn’t have 4-wheel drive or a high clearance. Especially in winter weather will we need ourJeep?
No
Yes
Submit
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