IN-HOME EUTHANASIA
This form is intended to help prepare both you and us for your upcoming appointment.
Please be sure to complete this form and submit it to us as quickly as possible so as not to delay your scheduled appointment.
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Email *
Untitled Title
Today's Date *
MM
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DD
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YYYY
COLLECTION OF PERSONAL INFORMATION *
Greenwood Veterinary House Call Services has a personal information policy in accordance with the requirements of the Personal Information and Electronic Documents Act.  This information is used to maintain complete and accurate client files; provide goods and services to veterinary clients, including contacting clients to schedule appointments and follow-up on patient treatment, billing for goods and services and notifying clients about new services and promotional offers; and communicating and working with third parties providing veterinary medical or other services to clients, including other veterinary facilities and insurance companies which may pay for all or part of the cost of such services.  This information will not be used or disclosed for purposes other than those for which it was collected, except with my consent, or except where use of disclosure is required by law.
Required
Your First Name *
Your Last Name *
Street Address *
City *
Postal Code *
Format: X9X 9X9
Preferred Phone Number *
(xxx) xxx-xxxx
Other people who may be present for the euthanasia *
This may include your spouse/partner, child, friend, etc.   Please provide first name and relation to you (ex. John - spouse)
Are there children in the household? *
Regardless of whether or not they will be present, if you have children in your household please provide their ages so that we can provide additional support material to help you guide them through their loss.
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