Heartland Home Veterinary Care Client and Patient Information sheet
*Aftercare Only*
Dr. Decker will contact you within 24 hours to go over things and set up a time to meet.
Full Name
*
First Name
Last Name
Address for appointment
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this your mailing address as well?
*
Yes
No. Please provide one below:
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Is it okay to text this phone number?
Please Select
Yes
No
Preferred method of communication
Call
Text
Email
Pet name
*
Species of pet (cat, dog, etc).
*
Breed
*
Pet's Age (can add birthdate if known)
*
Pet's sex
*
Please Select
Male-neutered
Female-spayed
Male-intact
Female-intact
Pet's color/markings
Pet's weight in pounds
*
What day did your pet pass?
*
-
Month
-
Day
Year
Date
What questions do you have for us?
Is there someone in the home who can help the veterinarian carry the pet on a stretcher to her vehicle if needed?
*
Yes
No
N/A
Do you know what aftercare option you will be selecting for your pet?
*
Private cremation through Heartland Home Veterinary Care (Ashes are returned)
Communal cremation through Heartland Home Veterinary Care (Ashes are not returned)
Other
If electing for private cremation in the Brownwood region, what urn choice would you like to choose?
Standard plastic Eco-urn. No additional charge.
Scatter bag: $10.
Cedar Box with name engraving: $80.
Metal urn with paw prints: Small: $40, Medium: $65, Large: $75.
Would you to have a clay paw print made as a memorial for your pet? This service is an additional $40.00.
*
Yes
No
Who is your pet's regular veterinarian and would you like us to contact them to inform them of your pet's passing?
How did you hear about Dr. Decker and Heartland Home Veterinary Care?
Any concerns? Questions to ask owners? Thoughts or notes?
Submit
Should be Empty: