Owner Name*

Co-Owner's Name

Primary Phone*

Email Address*

Address*

Apt. #

City*

State*

ZIP code*

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*

Breed*

Color*

Pet's Date of Birth (mm/dd/yyyy)*

Weight (in pounds)*

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*

Female intact

Female spayed

Male intact

Male neutered

Does your pet have a history of fear, anxiety, aggression or biting?*

Yes

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?

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

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

Urn Selection*

Cedar Memorial Urn

Hand-Carved Rosewood Urn

Serenity Photo Urn

Remembrance Urn

Decorative Metal Urn in Tan

Decorative Metal Urn in Blue

Blue Satin Bag

Blue Scatter Tube with Paw Prints

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 - $71.50

3 - $143.50

4 - $215.25

Please select # of ink paw prints desired*

Only available with individual or communal cremations.

0 - No cost

1 - $33.50

2 - $67.00

3 - $100.50

4 - $134.00

Please select # of ink nose prints desired*

Only available with individual or communal cremations.

0 - No cost

1 - $33.50

2 - $67.00

3 - $100.50

4 - $134.00

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 - $42.75

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*

Date*

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.

Pet Hospice In-Home Euthanasia Form Houston, TX

Consent for Services

Records and Communication Policy

Data Privacy Notice

Pet Hospice
In-Home Euthanasia Form
Houston, TX