Angel Wings New Client Form

Angel Wings New Client Form

We realize this time is difficult, but please do your best to fill out this form as completely as possible. If this form is overwhelming, you can simply give us a call at (877) 912-6435 and one of our care representatives can help you complete it.
Client Information
Full Name (First)
First Name
(Last)
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Address 2
Apartment or Unit Number
City
State
Zip Code
Special Instructions so our Veterinarian can find you (i.e. Unit 204 is to the left of the pool, gate code is #1234, driveway parking ok, etc.)
Pet Information
Pet's Name
Color
Share a photo of your angel with us?

We will NEVER share this image on social media without express permission. This is just so our team can see how sweet and beautiful and unique your pet is.
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Type of Pet
Breed
Age
Gender
Pet's Weight
Pounds (lbs)
Has your pet bitten any human in the last 10 days
California law requires that any animal that has bitten a human must be quarantined for 10 days before a euthanasia appointment can be fufilled. The bite MUST be reported to the local health officer before Angel Wings can proceed with appointment scheduling. Please call us if you have questions on who to contact in your area.
Medical History

Please provide any relevant medical history for your pet.
What is your pet's main diagnosis (if any) from your primary or emergency veterinarian?
Please list the most relevant health concerns over the past 2 months that are affecting your pet's quality of life. (e.g. stopped eating, crying out, can't walk, etc.)
Symptoms (Please check all that apply):
Vision
Hearing
Mobility
Neurologic
Eating/Drinking Habits
Sleeping Habits
Gastrointestinal
Urination/Defecation
Respiratory
Blood Loss
Skin/Grooming
Additional Comments
Anything else we should know about your pet (e.g. She is very nervous, he is not acting right, loves belly rubs)
Preferred Appointment Type
*Local Parks and Beach euthanasias will incur an additional $75.00 fee to cover additional time, semantics, and/or parking fees)
Aftercare Preference
** Private Cremations include a beautiful carved wooden urn with your pet's name, and communal cremation pets are laid to rest in the ocean with their furry friends. Both incur additional fees based on pet weight.
Early Arrival Ok?
Sometimes our veterinarians will be in your area earlier than the scheduled appointment time, and MAY be able to arrive early. Please let us know if this would be OK.
NON-MARKETING SMS DISCLAIMER: Do you agree to receive text messages from Angel Wings In Home Pet Euthanasia, A Veterinary Corporation, sent from (877) 912-6435? Message frequency varies and may include updates on your appointment status, or important updates regarding your appointment. Message and data rates may apply. Reply STOP or CANCEL at anytime to end or unsubscribe. For assistance, reply HELP or contact support at : (877) 912-6435.
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Please verify that you are human
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Angel Wings New Client Form

Client Information

Pet Information

Medical History