Pet Euthanasia Form
Our End of Life program is currently offered weekdays at our KW Centre at 250 Riverbend Dr. Here you’ll find a peaceful, private space for you and your pet.
Owner Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tell us about your pet:
Name:
*
Species:
*
Breed:
*
Colour:
*
Age:
*
Gender:
*
Male
Female
Is your pet spayed/neutered?
*
Yes
No
Approximate weight (please indicate in lbs or kgs):
*
Has your pet bitten or scratched anyone in the last 10 days (where it broke skin)?
Yes
No
Has your pet seen the vet in the past 12 months?
*
Yes
No
If yes, what is the name of the Veterinary Clinic?
*
If no, please put N/A
Do you give us permission to contact your clinic for your pets records?
*
Yes
No
How did you hear about our End of Life Care program?
*
Social media
Flyer/poster
HSKWSP newsletter
Word of mouth
HSKWSP Website
Other
Please let us know the reason that has lead you to inquire about euthanasia:
*
What are your cremation needs?
*
Private (Ashes returned to owner)
Communal (No ashes returned)
I don't know yet
Consent
*
I agree and understand I will not with my pet during the euthanasia. Due to space limitations at the facility, we want to be sure you understand you will not be able to be physically present with your animal during the euthanasia process
Consent
*
The Humane Society of Kitchener Waterloo and Stratford Perth is able to offer this service at an affordable cost to serve members of our community. Payment must be received prior to the appointment day via e-transfer. E-transfer information will be provided to you once an appointment has been confirmed.
Submit
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