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. I understand I will receive an email promptly and have 24 hours to decide on any additional memorial keepsakes. 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 *
THE FEDERAL AND PROVINCIAL GOVERNMENTS HAVE ASKED TO MAINTAIN SOCIAL DISTANCING OF AT LEAST 2 METERS (6 FEET). BY ACKNOWLEDGING THIS FORM YOU RECONGNISE IT MAY NOT BE POSSIBLE TO MAINTAIN THIS DISTANCE WHILE YOUR PET IS RECEIVING CARE THAT YOU MUST BE PRESENT FOR.
MISREPRESENTING YOURSELF ON THIS FORM
WILL PUT ALL STAFF AND CLIENTS AT RISK. WE MUST ENSURE OUR SAFETY SO WE CAN ASSIST ALL PATIENTS IN NEED. WE ASK YOU TO BE HONEST SO WE DO NTO RISK CLOSURE OF THE CLINIC AND APPRECIATE YOUR ASSISTANCE IN THIS MANNER.
IF COMING INTO THE CLINIC, YOU MAY BE ASKED TO HAVE YOUR TEMPERATURE TAKEN. THIS WILL BE A REQUIREMENT, NOT AN OPTION. IF YOU ARE SHOWING ANY OF THE COVID-19 SCREENING SYMPTOMS WHEN COMING TO THE CLINIC YOU WILL BE ASKED TO LEAVE FOR EVERYONE'S SAFETY.
PLEASE STAY HOME, SELF ISOLATE AND CONTACT YOUR HEALTH CARE PROVIDER OR TELEHEALTH ONTARIO (1-866-797-0000) TO FIND OUT IF YOU NEED TO BE TESTED FOR COVID-19. I understand and agree