Client/Patient Intake

1 Client Information

First Name *

Last Name *

Email Address *

Phone Number

Address

City

State

ZIP Code

Have you used our services before?

Yes No

Were you referred by someone?

2 Pet Information

Pet Name *

Species *

Breed

Age

Weight

Medical Notes / History

3 Visit Preparation

Help us arrive prepared so we can give your pet the best possible care.

My pet may require oral sedation for behavioral reasons For pets that may be anxious or difficult to handle

I would like the veterinarian and team to wear masks during the visit For the safety and comfort of everyone present

Does your pet currently have or recently had an active infection or condition we should know about?

Examples: pneumonia, open wounds, skin infections, fly/maggot involvement, contagious illness, etc.

4 Service Request

Where would you like the appointment to take place? *

In Your Home

We come to you. Includes travel, veterinary procedure (sedation/euthanasia), transport to West Coast Pet Memorial Center in Colbert, and cremation with return of ashes in one of 4 standard urns. Specialty urns and additional memorial items available at additional cost through the pet memorial portal after your appointment.

Our Comfort Suite — Spokane Valley

Private entrance and driveway. Remodeled detached space dedicated entirely to your pet's care. Anyone and other pets are welcome. Usually available sooner and more cost-effective. All the same care and attention — just at our location.

Additional notes about the service you're requesting

Primary clinic notification: If your pet has been seen within the last 12 months, we will notify your primary clinic that their patient was humanely euthanized at home. If memorial items are requested, you may be able to arrange pickup through your primary clinic — we will communicate this through West Coast Pet Memorial Service when they contact you to let you know your pet is ready for pickup at their location in Colbert.

5 Aftercare & Cremation

Aftercare preference

West Coast Pet Memorial Service — Colbert, WA (Recommended)

Our trusted provider. Within 24 hours of your appointment, you'll receive an email from PawEtrack with access to your pet's memorial portal. Cremains are typically ready in 7–10 days — you can pick them up from West Coast or request shipping. Engravings on standard urns are included at no extra cost.

Home Burial

Please be aware of your county's regulations regarding home burial of pets before selecting this option.

Other Provider

You have arranged aftercare with another provider. Please describe in the notes field below.

Undecided — I'll decide later

That's okay. You'll have 24 hours after your appointment to make a selection through the PawEtrack memorial portal.

Standard Urn Options

The Cedar Memorial Urn is selected by default. After your appointment, you can confirm or change your urn selection and add a personalized engraving at no extra cost through the memorial portal. Specialty urns and additional memorial items are available at an additional cost — billed through West Coast Pet Memorial (they accept CareCredit).

Cedar Memorial Urn

Default Selection

Classic White Urn

Standard

Slate Gray Urn

Standard

Midnight Blue Urn

Standard

6 Appointment Preferences

7 Signature & Agreement

Choose Signature Method *

Draw Your Signature *

Full Legal Name *

I acknowledge that I have provided accurate information and authorize the services requested above. By signing, I agree to the terms of service and understand this is a legally binding electronic signature. *