Are you the person responsible for decisions and accounts? *
This person should be the owner on account, responsible for decisions, payments and of legal age. If you are not the owner, the owner is aware and gives you authorization to attend this appointment and complete this form on their behalf. The owner has emailed the clinic this authorization.
Date and Time of your appointment * Email *
Phone number you can be reached at? *
Please keep your phone on and be available to answer.
Pet Name * I wish to have my pets ashes returned *
and acknowledge there is an additional charge for this. If Yes, please also complete the next question for your choice of urns.
Complimentary urn choices
Complimentary urns can be viewed under STANDARD URNS at https://www.gatewaypetmemorial.com/memorial-products-ontario/
Please indicate the name of the one you would like below.
After your visit with us today you will receive an email from Gateway Pet Memorial. This way you will have 24 hours at home in private to review any additional memorial keepsakes you may like. Please let us know if you need any help or have any questions. Euthanasia protocol *
Please note due to our one person per pet policy we have implement the below procedures to our practice. For a euthanasia, we will allow up to 2 people. Unfortunately there will be no access to the washroom facility. We appreciate your understanding, and we will try to assist you during this difficult time.
COVID-19 Screening *
I acknowledge that I have not been outside of Canada nor have been in close contact with someone that has been confirmed OR probable positive case of COVID-19 in the last 14 days.
I acknowledge that I have not been in a facility in the last 14days that has had a positive outbreak of COVID-19.
I acknowledge that I do not have a temperature of 38 degree or more, and do not have a runny/stuffy nose or nasal congestion (not due to allergies).
I acknowledge that I do not have a cough, sore throat, trouble swallowing shortness of breath or loss of taste or smell.
I acknowledge that I do not have any 2 of the following? Muscle aches, chills, fatigue, conjunctivitis, headache, unknown skin rash, nausea, diarrhea or loss of appetite?
Acknowledgement of COVID-19 questionnaire *