Pet Hospice | In-Home Euthanasia Form

Owner Name*
Co-Owner's Name
Primary Phone*
Email Address*
Address*
Apt. #
City*
State*
ZIP code*
Pet's Name*
Species*
Breed*
Color*
Pet's Date of Birth (mm/dd/yyyy)*
MM slash DD slash YYYY
Weight*
Sex*
- Female Intact
- Female Spayed
- Male Intact
- Male Neutered
Does your pet have a history of fear, anxiety, aggression or biting?*
- Yes (We will contact you if further discussion is needed)
- No
Provide details about your pet's current condition, diagnosis, and symptoms they are experiencing.*
Please list your pet's primary veterinarian*
How did you hear about us?
Additional Instructions
Aftercare Options

Cost includes euthanasia and travel fee

Premium Cremation Package: The package includes cremation, choice of urn with custom name plate for wooden urns, a complementary claw paw print and shipping.

Basic Cremation Package: The package includes cremation, a hand carved rosewood urn, complementary clay paw print and shipping.

Communal Cremation Package: The package includes cremation, a complementary clay paw print and shipping. Your pet's ashes are respectfully scattered in a memorial garden.

Owner Responsible: If you choose 'Owner Responsible' for your pet, the owner will be responsible for aftercare, including cremation, aquamation, or home burial.
Select Aftercare*
- Premium Cremation Package
- Basic Cremation Package
- Communal Cremation Package
- Owner Responsible
Stretcher Assistance Acknowledgement*
If the patient is 51-100lbs, someone in the home will need to assist the provider with a stretcher
If the patient is 100-150lbs-at least 2 people need to be available to assist the provider with a stretcher
If the patient is 151lbs or more, we're unable to help with aftercare
I understand that stretcher assistance may be required, and that "Owner Responsible" is required for pets over 151 lbs
If you selected the Premium Cremation Package, what would you like your pet's ashes to be returned to you in?
- Cedar Memorial Urn
- Hand-Carved Rosewood Urn
- Remembrance Standard Urn
- Serenity Photo Urn
- Decorative Metal Urn - Blue
- Decorative Metal Urn - Tan
If you selected the Premium Cremation Package, please personalize your pet's urn nameplate below
Maximum of 14 characters per line.
Line 1 Line 2
Additional Memorial Items
Available with any cremation package
Please select # of white clay paw prints desired*
- 0
- 1
- 2
- 3
- 4
Please select return method*
- N/A (no memorial items to return)
- Pick up at BluePearl Pet Hospital
- UPS Signature Mail
For UPS Signature Mail, please provide a return shipping address. Ashes and paw prints sent via UPS Signature Mail will require a signature release upon delivery.
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Consent for Services
Consent for Euthanasia: As owner or authorized agent for the pet described hereon, I hereby give consent for euthanasia (humane death) services. I further authorize BluePearl Pet Hospice to care for the handling of my pet's cremation, if elected, through our partner crematorium. To the best of my knowledge and belief, this pet has not bitten any person during the last 10 days.
Records and Communication Policy
BluePearl Pet Hospice is part of your pet’s continuum of care, and we may provide your family veterinarian, any specialists, and/or a reviewing body information regarding your pet’s treatment and/or condition. By signing below, you are authorizing BluePearl Pet Hospice to share your pet’s medical record with a third party (such as your family veterinarian) or its agent necessary for us to provide continuous veterinary care to your pet. You agree that we (or our agents) may send you communications to your contact information provided above regarding your pet.
Client Signature*
Date*
MM slash DD slash YYYY
Data Privacy Notice
BluePearl and our affiliated entities are committed to providing quality and informed services to and for you and your pet. We aim to be your partner in your pet's long-term health and happiness through a variety of means, including by considering research, diagnosis and analysis from across our vet hospitals and brands. As part of this mission, we work with our affiliates, parent and subsidiaries to provide the services you request and to analyze and evaluate the patterns of diagnosis and treatment of the pets treated at our facilities. From time to time we, BluePearl, and our affiliates, may also use the data collected from you and your pet for research and for advertising and promotion of goods and services that may be of interest and beneficial to you and your pet. For more information on our policies and information on how to opt-out of some forms of sharing, please see our Privacy Policy at https://www.mars.com/privacy.
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Pet Hospice In-Home Euthanasia Form Glendale, WI

Consent for Services

Records and Communication Policy

Data Privacy Notice

Pet Hospice
In-Home Euthanasia Form
Glendale, WI