First Name Last Name Address City Postal Code Mobile Number (enter numbers only) Secondary Number Email Pet's Name Breed Colour Date of Birth Approximate Weight Gender of Pet Male Female Is Your Pet Neutered/Spayed Yes No Current Vet Clinic By clicking on this, I consent to having York Mobile Veterinary Services request for my pet's medical records Rate your pet's comfort with new people visiting your home May bite/scratch Will run/hide Shy but friendly Easily distracted with treats Loves everyone I am looking for End of LIfe Care Appointment Within 24-48hrs Within 1 week Within 2 weeks I am not ready to book the end of life appointment but would like to book a Consultation for Palliative Care/End of Life because I am unsure of timing After Care Decisions I would like my pet privately cremated in his/her own chamber and cremains to be returned to me I would like my pet cremated with other pets and understand that his/her cremains will not be returned Undecided I would like a Paw Print (made by Gateway Pet Memorial) Yes No Reason for Appointment How did you hear about us? Google Facebook/Instagram Referral Other If you checked referral, who can we thank? We accept payment via e-transfer or credit card. Communication with us can be done through phone calls, emails or text messaging. When you submit this form, you are consenting to receiving text messaging. Please let us know if you would like to opt out of text messaging. Send