Intake Form

Owner Information

First name*

Last name*

Multi-line address

Country/Region*

Address*

Address - line 2

City*

Zip / Postal code*

Phone*

Email*

Are you the Sole Owner?*

Yes

If no, Please add Co-Owner Name and Number

Name and Number

Pet Information

Pet's Name*

Species*

If Other, Please Specify

Breed

Colour

Age

Weight*

Gender*

Male

Female

Neutered Male

Spayed Female

Has your Pet Passed?*

Date of Death

Are there any veterinarians or other pet care professionals that you would like us to notify?

Will you require transportation of your animal?*

Yes

After Care Arrangement Options

Authorization: I certify that I am the owner, or authorized agent of the owner, of the pet described above and that I am 18 years of age or older. I understand that aquamation (water cremation) is an irreversible process.

I wish to have Furever Aquamation Services arrange for my pet's aftercare (you must select one of the following):*

Unclaimed Remains: I understand if my pet's remains are unclaimed for 90 days after notification of remains availability, Furever Aquamation reserves the right to dispose of the remains.

Release and Certification: I agree to release and indemnify Furever Aquamation, agents and employees, from any claim, liability, cost or expense resulting from their reliance on or performance consistent with the directions, authorizations and agreements herein. I agree that Furever Aquamation’s liability for negligent acts (of itself, agents, or employees) is limited to a refund of the aquamation's fees paid for this pet.

Signature*

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