Pet Name*Pet Parent* First Last Email* Phone*Does this number accepts text messages?*YesNoAddress where appt will take place* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this your mailing address?*YesNoMailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Instructions - cross streets, house color, cars, etc that will help me find your home.*How may we help you?*In Home EuthanasiaVirtual Quality of Life ConsultationHospice ConsultationWho is your pet's veterinarian?Veterinary Clinic NameWhat dates and times are you considering for your appointment or have been scheduled with Dr. Stephanie?*Please tell us about your pet's issue*Pet's name*Species*DogCatBreedPet's Age and/or Date of BirthWeight*Pet's weight*ExactEstimatedSex*MaleFemaleIs your pet spayed or neutered?*YesNoHas your pet bitten (and broken skin) on a person in the last 10 days?*YesNoMay we help with aftercare for your pet?*Private Traditional/Flame Based with ashes returned and a clay paw printPrivate Aquamation with ashes returned (plastic urn, paw print at additional fee)Communal cremation, no ashes returned (paw print at additional fee)Home Burial or handling cremation on my ownIf your pet is 35-90 pounds, do you have one person who can safely help lift your pet on a stretcher? If your pet is over 90 pounds, do you have two people who can safely help lift your pet on a stretcher? (We may be able to provide an extra person with enough notice)*YesNoIf you were referred, please let us know who sent you our way.Do we have your authorization to post a memorial about your pet? Your pet's first name and an included photo would be the only identifier.*YesNoIf you would like, please upload a photo of your petI understand that all present MUST PROPERLY wear a mask for the ENTIRE visit and every effort will be made for the appointment to take place outside if possible and appropriate.*YesNo
