Patient Registration Form - Helping Hands Pet Hospice

What county do you live in? *

If other, please specify which county: *

Pet Parent - Please use the same name you use at your vet's office *

First

Last

If you or anyone we will be meeting would like to share your pronouns or your preferred way to be addressed, please let us know here. Please also let us know if you have customs or special needs we should be aware of.

Address Where Appointment Will Take Place *

Address Line 1

Address Line 2

City

State

Zip Code

Is this your mailing address? *

Yes
No

Have you used our services before? *

Yes
No

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

What other family members will be involved in your pet's appointment?

Instructions - cross streets, house color, cars, etc that will help me find your home.

How may we help you? *

Virtual Quality of Life Consultation
House Call Euthanasia
Other

Other Request

What dates and times are you considering for your appointment?

These are only requests for days and times, not a guarantee. No appointment has been scheduled until we confirm with you.

Pet Information

Please tell us a little about your pet's issue *

Pet Name *

Species *

Cat
Dog
Rabbit
Other

What species is your pet?

Breed *

Pet's Date of Birth *

Exact date of birth or estimated date of birth? *

Exact
Estimated

Weight *

Enter weight in pounds.

Color *

Sex *

Male
Female

Is your pet spayed or neutered? *

YES
NO

How did you hear about us?

If "other," please explain:

If you were referred, please let us know who sent you so we can thank them!

Who is your pet's veterinarian? We send a report with each appointment *

Veterinary Clinic Name (If a chain like Banfield, please put street name) *

What is YOUR email address? (please add info@hhphospice.com to your address book to avoid our emails going to SPAM.) *

What is YOUR phone number? *

Receive Texts at Above Number? *

YES
NO

Do you have pet insurance? Hospice care and euthanasia may be covered under your policy. *

YES
NO

Has your pet bitten (and broken skin) on a person in the last 10 days? *

YES my pet has bitten
NO my pet has not bitten anyone in the last 10 days.

Please explain, providing the date of the bite and the circumstances. *

Is your pet currently under quarantine for biting a person? *

YES
NO

Aftercare

May we help you with aftercare for your pet? *

Communal Cremation (your pet is cremated with other pets and the ashes are not returned to you)
Private Cremation (your pet is cremated by themselves and their ashes are returned to you)
I will be taking care of my pet's remains on my own
I want cremation but am unsure which type yet

Please select your pet's weight range (so we can show you the correct options below) *

0-29.9 pounds
30-49.9 pounds
50-89.9 pounds
90 pounds or more

Do you have one person who can safely help lift your pet on a stretcher?

Yes
No

30-49.99 lbs

If you cannot help the doctor lift your pet, we can help you say goodbye and then leave your pet with you so you can arrange for cremation pickup or burial. There are many options for cremation in our area. Honor Thy Pet will pick up from your home 24 hours a day 727-447-6980.

Will your pet need to be carried down a flight or more of stairs? (A few steps is fine)

Yes
No

50 lbs +

You’ve indicated your pet weighs 50 pounds or more and will need to be carried downstairs. At this time, we are unable to assist with transporting pets 50 pounds or more if stairs are involved. We can help you say goodbye and then leave your pet with you so you can arrange for cremation pickup or burial. There are many options for cremation in our area. Honor Thy Pet will pick up from your home 24 hours a day. 727-447-698

Do you have one person who can safely help lift your pet on a stretcher?

Yes
No

If you cannot help the doctor lift your pet, we can help you say goodbye and then leave your pet with you so you can arrange for cremation pickup or burial. There are many options for cremation in our area. Honor Thy Pet will pick up from your home 24 hours a day. 727-447-6980.

You’ve indicated your pet weighs 90 pounds or more. At this time, we are unable to assist with transporting pets 90 pounds or more for cremation services. We can help you say goodbye and then leave your pet with you so you can arrange for cremation pickup or burial. There are many options for cremation in our area. Honor Thy Pet will pick up from your home 24 hours a day.727-447-6980

All families will receive (if they desire) one Pawpals foam paw print impression and one lock of fur from their pet. Click the links below to preview additional items.

Please select any additional items you would like.

Additional PawPals foam paw print - $35
Additional locks of fur - $0
Clay Paw Print from Pet Angel (only available with cremation services) - $45
Ink Paw Print from Pet Angel (only available with cremation services) - $45

Please select any additional items you would like.

Additional PawPals foam paw print - $35
Additional locks of fur - $0

Additional PawPals Foam Paw Print - How many would you like?

Additional Locks of Fur - How many would you like?

Clay Paw Prints - How many would you like?

Ink Paw Prints - How many would you like?

Private cremations include a choice of seven different urns or a velvet pouch. Your beloved pet’s ashes will be placed inside a clear pouch and then a blue silk pouch before going into an urn. All urns are able to be opened.The scattering tube urn is made of heavy paper and has no pouch inside. Ashes are secure until you push in the perforated circle at the time of scattering. Click the links below to preview each option. If you are not ready to make a choice or want to upgrade to a different urn, please let us know below. Engraving options will appear once you have selected an urn.

Please select an urn *

Would you like your urn engraved ($60 for up to 3 lines. Lines are limited to 30 characters including spaces)? *

YES
NO

Please select any additional items *

Etched directly into the wood ($60) - up to 2 lines of 20 characters each
Engraved brass nameplate ($60) - up to 3 lines of 26 characters each
None of the above

Please specify the message you'd like engraved in this box.

Please Note: The engraving on the Blue Metal Urn isn’t as visible as the other urns.

Where would you like to pick up your pet's ashes? *

My veterinarian's office
Pet Angel (13100 56th Ct N Clearwater - off of Ulmerton Rd between US 19 and 49th St)
I prefer to have them shipped (signature required) to my home or office - $40

Where would you like to pick up your memorial items? *

My veterinarian's office
Pet Angel (13100 56th Ct N Clearwater - off of Ulmerton Rd between US 19 and 49th St)
I prefer to have them shipped (signature required) to my home or office - $40

Special instructions (division of ashes, upgrade urn, multiple urns, etc) may be entered here if you wish: