Euthanasia Appointment

Owner’s Name (required)

Owner’s Phone Number (required)

Owner’s Email Address (required)

Street Address (Required)

City, State, Zip (required)

Where would you like the visit?

House Call

At our Comfort Center

Pet’s Name (required)

Pet’s Species (Dog/Cat/Other) and Breed (required)

Pet’s Age (required)

Pet’s Weight (required)

Preferred Appointment Date and Time (required)

Who is your regular veterinarian?

Reason for Euthanasia Request

Which type of aftercare (choose one)

Private Cremation (ashes returned)

Communal Cremation (ashes not returned)

Home Burial (local laws apply)

Undecided at this time

Has your pet bitten anyone in the last 10 days?

Additional Notes or Questions