Pet Hospice | In-Home Euthanasia Form | Houston, TX
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Pet Hospice In-Home Euthanasia Form Houston, TX
Owner Name
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Co-Owner's Name
Primary Phone
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ZIP code
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Preferred date/time
After you submit this form, a member of our Care Team will contact you to schedule your in-home visit.
Preferred method of payment
*
Credit card
Debit card
CareCredit
Pet's Name
*
Species
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Breed
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Color
*
Pet's Date of Birth (mm/dd/yyyy)
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MM slash DD slash YYYY
Weight (in pounds)
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Aftercare weight limit acknowledgement
*
I understand that pets over 80 lbs are subject to special scheduling requirements and/or additional fees. The BluePearl Pet Hospice Care Team will be in touch following the submission of this form.
I understand
Sex
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Female intact
Female spayed
Male intact
Male neutered
Does your pet have a history of fear, anxiety, aggression or biting?
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Yes
No
Please provide any details about your pet's history of fear, anxiety, aggression or biting.
*
Our team may follow up regarding these behaviors.
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?
Choose one
Word of Mouth
Other Advertisement
I'm a Previous Client
BluePearl Pet Hospital
My Primary Vet
Social Media
Search (Google)
Yelp
Additional Instructions
Aftercare Options
Owner Responsible - No Cost: If you choose 'Owner Responsible' for your pet, the owner will be responsible for aftercare, including cremation or home burial.
Select Aftercare
*
Individual cremation (ashes are returned) - $347.75
Communal cremation (ashes are NOT returned) - $95.50
Owner responsible - no cost
For pets over 40 pounds, we use a stretcher for respectful transport from home to vehicle. Is someone in your home able to help carry one end of the stretcher?
Yes
No
What would you like your pet's ashes to be returned to you in?
Urn - no cost - 6 styles available to choose from at time of appointment confirmation
Engraved name plate included with urn - no cost
Velvet bag - no cost/no engraving
Engraving instructions (maximum 30 characters - please verify spelling)
Additional Memorial Items
Please select # of fur clippings desired
*
0 - no cost
1 - no cost
2 - no cost
3 - no cost
4 - no cost
Please select # of clay paw prints desired
*
0 - no cost
1 - no cost
2 - $67.00
3 - $134.00
4 - $201.00
Please select # of ink paw prints desired
*
Only available with individual or communal cremations.
0 - No cost
1 - $32.00
2 - $64.00
3 - $96.00
4 - $128.00
Please select # of ink nose prints desired
*
Only available with individual or communal cremations.
0 - No cost
1 - $32.00
2 - $64.00
3 - $96.00
4 - $128.00
Please select return method
*
N/A (no memorial items to return) - no cost
Pick up at BluePearl Spring Hospital (1646 Spring Cypress Road, Suite 100, Spring, TX 77388) - no cost
USPS Mail - $40.75
Pick up at primary veterinarian - no cost
If you selected USPS shipping, where should we ship to?
If you selected primary veterinarian pick up, please confirm their name and address.
USPS DISCLAIMER: BluePearl Pet Hospice is not responsible for loss, delay, damage, misdelivery, or other issues that occur after memorial items or cremated remains have been transferred to the United States Postal Service (USPS). By selecting USPS shipping, the client acknowledges and accepts responsibility for any risks associated with shipment.
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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 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 15 days.
Records and Communication Policy
BluePearl Specialty and Emergency Pet Hospital 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 Specialty and Emergency Pet Hospital 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
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Date
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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
.
