Vet Intake Form

MidCity Veterinary Hospital

504-304-8223
midcityvet@gmail.com
3821 Orleans Avenue
New Orleans Louisiana 70119 https://midcityvet.com/

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PLEASE COMPLETE BELOW TO NOTIFY HEAVEN'S PETS THAT YOU HAVE A PICKUP!

Our drivers will be notified and we will be there within 24-48 hours to pickup the pet. Once in our care, we will call the owner to go over the information and to proceed with the cremation unless otherwise noted by your office.

Pet Owner

First Name*

Last Name*

Email*

Phone*

Address*

City*

State*

Zip*

Pet

Pet Name*

Sex

Breed*

Weight*

Date of Birth

mm/dd/yy

Date of Death*

mm/dd/yy

Veterinarian

Worked with us before?

If so you can select your business from the list below to auto-fill your information.

Veterinary Hospital*

Veterinarian Name

First Last

Veterinarian or Clinic Email*

Please provide an email address so that we can send you a copy of this form for your records.

Veterinarian or Clinic Phone*

Address

Street Address Address Line 2 City State ZIP Code

Arrangements

Type of Cremation*

Private: A private cremation means that the pet will be placed and cremated ALONE in the cremation chamber. Cremation includes a lovely wooden urn containing pet's cremains, certificate of cremation and personalized poems in pet's memory.

Communal: A communal cremation means that the pet will be COMINGLED with other pets in our cremation chamber and their cremains will not be returned. A certificate of cremation and personalized poems are mailed to the owner.

CLINIC MASS: FEES COLLECTED AT CLINIC. NO CONTACT WITH OWNER AND NO CREMAINS OR KEEPSAKES RETURNED.

Fee Note

Special Instructions

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ClientEmail

Phone

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