Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Client InformationFull Name *Phone *Address *City *State *Zip Code *Email Address *Preferred Method of Contact: *PhoneTextEmailPet InformationPet's Name: *Breed *Age *Approximate Weight *Gender *MaleFemaleReproductive Status *Spayed or NeuteredIntactColoring/Specific markings Current Medical Conditions (if any)Primary Veterinary ClinicHas your pet ever shown aggression or anxiety with handling? *YesNoYes *Oral sedation medication prescribed by your primary veterinarian and/or a muzzle may be required to handle aggressive pets.Home Burial and Cremation Options (pricing available in the FAQ/Pricing tab on our website) *Home Burial - I will provide my own bag/boxHome Burial - Biodegradable bag provided by Gentle Journey ($20)Group Cremation - Ashes NOT returned to me. Ashes dispersed in the mountains on private property in Morgan, UtahIndividual Cremation - Ashes returned to me in a complimentary metal tin, or walnut/cedar wooden boxBox/Urn Selection *Yes, I would like a complimentary box/tinYes, I would like to purchase a Premium Metal Urn rather than a boxNo, I would not like a box, tin, or metal urnBox Selection *Metal TinCedar Box - with clasp and lock (Beautifully handcrafted aromatic cedar urn with a lid, secured using a clasp and lock with key. This option allows easy access if needed. Each urn can be personalized to best memorialize your pet.)Cedar Box - Sealed (Beautifully handcrafted aromatic cedar urn with a smooth, sealed finish and screw-on base. This option provides a clean and secure closure. Each urn can be personalized to best memorialize your pet.)Walnut Box with clasp and lock (Beautiful handcrafted walnut urn with a lid, secured using a clasp and lock with key. This option allows easy access if needed. Each urn can be personalized to best memorialize your pet.)Walnut Box - Sealed (Beautiful handcrafted walnut urn with a smooth, sealed finish and screw-on base. This option provides a clean and secure closure. Each urn can be personalized to best memorialize your pet.)Engraving (for Cedar and Walnut Boxes Only) - Includes 2 lines of engraving - Additional lines $15 per line *Yes ($35)NoEngraving Detail Clear SignaturePlease draw the engraving details as if this were the lid of the box, including text and clipart placement.Font Selectionfont 1font 2font 3font 4font 5font 6font 7font 8Clip Art ($20 per image)Clip Art 1Clip Art 2Clip Art 3Clip Art 4Clip Art 5Clip Art 6Clip Art 7Clip Art 8Clip Art 9Clip Art 10Clip Art 11Please include as much detail as possible regarding engraving/clipart size and placement * *Additions to Wooden Boxes *Metal Plate over Lid - No Engraving ($30)Metal Plate over Lid - with Engraving ($55)Plexiglass over Lid ($30)Your Pet's Paw Print engraved on lid ($50)Premium Metal Urn Size *Small Metal Urn (1-50 pounds) $125Large Metal Urn (50-125 pounds) $155Premium Metal Urn Style *Gold with 3 RingsSilver with 3 RingsGold with Paw PrintsSilver with Paw PrintsName on Paw PrintPaw Print (Ceramic, Granite, Glass tile) *Please allow 6-8 weeks for delivery of Ceramic Paw Prints)Ceramic Paw Print ($95 each)(Available colors - Blue, Pink, Black, Purple, Red)Ceramic Paw Print Quantity--- Select Quantity ---12345Paint Color 1--- Select Color ---BluePinkBlackPurpleRedNo PaintRibbon Color 1--- Select Color ---BluePinkBlackPurpleRedNo RibbonPaint Color 2--- Select Color ---BluePinkBlackPurpleRedNo PaintRibbon Color 2--- Select Color ---BluePinkBlackPurpleRedNo RibbonPaint Color 3--- Select Color ---BluePinkBlackPurpleRedNo PaintRibbon Color 3--- Select Color ---BluePinkBlackPurpleRedNo RibbonPaint Color 4--- Select Color ---BluePinkBlackPurpleRedNo PaintRibbon Color 4--- Select Color ---BluePinkBlackPurpleRedNo RibbonPaint Color 5--- Select Color ---BluePinkBlackPurpleRedNo PaintRibbon Color 5--- Select Color ---BluePinkBlackPurpleRedNo RibbonPaw Print - Granite Polymer Paw PrintGranite Polymer Paw Print ($95 each)(Available colors - Blue, Pink, Black, Purple, Red)Granite Polymer Paw Print Quantity --- Select Quantity ---12345Ribbon Color 1--- Select Color ---BluePinkBlackPurpleRedNo RibbonRibbon Color 2--- Select Color ---BluePinkBlackPurpleRedNo RibbonRibbon Color 3--- Select Color ---BluePinkBlackPurpleRedNo RibbonRibbon Color 4--- Select Color ---BluePinkBlackPurpleRedNo RibbonRibbon Color 5--- Select Color ---BluePinkBlackPurpleRedNo RibbonPawprint -Glass Tile Paw PrintGlass Tile Paw Print ($85 each)(Available colors - Black, Blue, Green, Red, and Brown)Glass Tile Paw Print Quantity--- Select Quantity ---12345Glass Color 1--- Select Choice ---BlackBlueGreenRedBrownGlass Color 2--- Select Choice ---BlackBlueGreenRedBrownGlass Color 3--- Select Choice ---BlackBlueGreenRedBrownGlass Color 4--- Select Choice ---BlackBlueGreenRedBrownGlass Color 5--- Select Choice ---BlackBlueGreenRedBrownPaw Print -No paw printNo Paw PrintInk Print Types (5 prints on card stock) *Ink PAW Prints ($35 for 5 cards)Ink NOSE Prints ($50 for 5 cards)Ink Paw Print Quantity (One set = 5 cards, two sets = 10 cards, etc.) *--- Select Quantity ---5 Cards10 Cards15 Cards20 Cards25 CardsInk Nose Print Quantity (One set = 5 cards, two sets = 10 cards, etc.) *--- Select Quantity ---5 Cards10 Cards15 Cards20 Cards25 CardsNecklaces- $65 each (Only available with Private Cremation - Each necklace is able to hold a small amount of ashes) *Tear Drop Shape "Faithful Friend"Heart Shape with Blue Rinestone Heart PawHeart Shape with Pink Rinestone Heart PawNecklace-Heart Shape with Black Paw PrintsCylinder Shape with Black Paw PrintsRound with Black Designs and Paw PrintPaw Print shaped Necklace with clear RhinestonesQuantity for Teardrop Shape Necklace with "Faithful Friend" Writing *--- Select Quantity ---12345Quantity for Heart Shape Necklace with Blue Rinestone Heart Paw *--- Select Quantity ---12345Quantity for Heart Shape Necklace with Pink Rinestone Heart Paw *--- Select Quantity ---12345Quantity for Heart Shape Necklace with Black Paw Prints *--- Select Quantity ---12345Quantity for Cylinder Necklace with Black Paw Prints *--- Select Quantity ---12345Quantity for Round Necklace with Black Design and Paw Prints *--- Select Quantity ---12345Quantity for Paw Print shaped Necklace with clear Rhinestones *--- Select Quantity ---12345Picture Frame with Clay Paw PrintYes ($95)NoPicture Frame with Clay Paw Print Quantity--- Select Quantity ---12345 Please list any personal items to be cremated with pet (blanket, toy, collar, etc...) *Scheduling Requirements and Payment Agreement *Your pet will be added to the Gentle Journey schedule once the Service & Remembrance Form is submitted and a consultation via text, phone, or email with a Gentle Journey veterinarian has been completed. A link for payment will then be sent from Square Pay via text or email and payment is required in full prior to a Gentle Journey veterinarian coming to your home.Euthanasia Agreement *I am the owner or duly authorized agent for the owner of the animal described above, and I have authority to make decisions regarding their care.I certify that to the best of my knowledge, the pet listed above has not bitten any person or animal within the past 15 (fifteen) days and has not been exposed to rabies. Acknowledgement of Mobile Service Limitations *Gentle Journey provides in-home humane euthanasia only, and does not provide emergency services, hospitalization, or general wellness care. Our veterinarian may arrive alone or with a technician at their discretion and may require assistance from pet owners/other family members for pet positioning, restraint, or transport - particularly for dogs weighing over 40 pounds.Consent to Treatment *I give Gentle Journey's veterinarian(s) permission to humanely euthanize my pet as requestedI have disclosed any history of aggression or fear-based behavior (including growling, snapping, or biting), and I understand that undisclosed behavior risks may affect how the appointment proceeds and may require additional safety measures or assistance. If my pet is aggressive during the visit without prior notification, the visit may need to be rescheduled until calming medication can be obtained and I will still be financially responsible for the housecall portion of the visit, whether or not treatment is completed.Transportation *Unless otherwise directed, your pet will be respectfully transferred to Wasatch Family Pet Services for cremation according to the aftercare option selected above. If ashes or remembrance items are to be returned, Wasatch Family Pet Services will deliver these items to your home upon completion, and they will contact you to discuss scheduling.Communication and Privacy Consent *I consent to being contacted via phone, text, or email for all communication regarding my pet's appointment, updates, and any information regarding aftercare or follow-up from Gentle Journey or Wasatch Family Pet Services if they are handling my pet's cremation/remembrance itemsGentle Journey will never sell or share personal information with anyone other than Wasatch Family Pet Services.Gentle Journey promises that every effort will be made to ensure your pet's comfort, peace, and dignity throughout the entire process. By signing below you are releasing Gentle Journey Veterinary Care and its representatives from any liability related to the euthanasia procedure or aftercare once the pet has been transferred to the cremation service provider. You are also agreeing to the terms listed in Gentle Journey's Client Service Agreement as listed on the website. Approximate Clay Signature * Clear SignaturePrinted Name *Date *How did you hear about Gentle Journey? *Internet SearchWord-of-MouthSocial MediaBoarding or Grooming LocationOtherSend to Myself *YesNo Submit
