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Pet Hospice In-Home Euthanasia Form Overland Park
Owner Name
*
Co-Owner's Name
Primary Phone
*
Email Address
*
Address
*
Apt. #
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*
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*
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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?
Choose one
Word of Mouth
Other Advertisement
Previous Client of Pet Hospice
BluePearl Pet Hospital
My Primary Vet
Social Media
Search (Google)
Yelp
Additional Instructions
Aftercare Options
Private Cremation - $345.75 Your pet is cremated privately, and their ashes and clay paw print memorial will be returned to you. Communal Cremation - $96.75 Your pet is cremated with other pets and their ashes will be respectfully scattered. Owner Responsible - No Cost You, the owner, will be responsible for aftercare, including cremation, aquamation, or home burial.
Select Aftercare
*
Private (ashes are returned)
Communal (ashes are NOT returned)
Owner Responsible
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
Please select return method
*
N/A (no memorial items to return) - No Cost
USPS Mail - $30.00
Pick up at BluePearl Overland Park Hospital (11950 W 110th St, Overland Park, KS 66210) – No Cost
If you selected USPS shipping, where should we ship to?
Hidden
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
*
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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