Compassionate End-of-Life Registration Form

September 11, 2026

CLIENT INFORMATION

First Name

Last Name

Phone

Address

Postal Code

Co-Owner

Information regarding your pets can only be released to individuals listed as owners on file. Please advise our team if you would like to add additional names.

Name

Phone

PET INFORMATION

Pet Name

Date of Birth

Sex

Female Female Spayed Male Male Neutered

Species

Breed

Colour

Current Veterinarian

When was your pet last seen by a veterinarian?

Pet Insurance Coverage

Yes No

Insurance Provider

Policy Number

In accordance with the Privacy Act, I understand my rights to privacy and that personal information will not be released without my consent. I consent and authorize the disclosure of necessary personal and medical information required when communicating with other veterinarians, specialists and other relevant third parties.

I understand full payment is due at the time services are rendered. If I am unable to pay in full, I must notify Petzoic Vet Hospital team before initiating services. Accepted payment forms are cash, credit card (MasterCard and Visa) and debit card. I have read and understand the above payment information and agree to the payment terms.

I certify that all information provided is correct and that I am 18 years of age or older.

Your Signature

Compassionate End-of-Life Registration Form

CLIENT INFORMATION

PET INFORMATION

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