FIXING IT 2025 Appointment Intake Form

Appointment Request Form
Name

FirstLast
Email
example@example.com
Cell Number
Please enter a textable phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState
Zip Code
Distance Fee
You are outside of our service area. Appointments may still be available on a case by case basis.
Family Information
Please tell us a little about who else lives in your home - spouse, children, other pets, etc.
- Pet's Name
- Type of Pet
- Gender
- Breed
- (Approximate) Age
- Weight (round up to the nearest 5lb)
  ex. if weight is 18lb, put 20 etc.
- Color
- Additional Information
  Please us know what is going on with your pet and anything you would like us to know.
- Primary Veterinary Clinic
  If none, write n/a
- Primary Veterinary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Specialty Veterinary Clinic
  If none, write n/a
- Specialty Veterinary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Methods of Aftercare
  
  Owner Provided - Burial, etc. Dr. Fiona will not be taking body and coordinating cremation
  
  Aquamation - Gentle, water-based form of cremation
  Provided by Peaceful Pets
  - Private Aquamation - ashes will be returned to owner
  - Private Aquamation / CCPS Scatter - ashes will be returned to CCPS and scattered in our wildflower area
  - Communal Aquamation - NO ashes will be returned
  Flame Cremation - Traditional, flame-based form of cremation
  Provided by Fond Memories
  - Private Cremation - ashes will be returned to owner
  - Private Cremation / CCPS Scatter - ashes will be returned to CCPS and scattered in our wildflower area
  - Communal Cremation - NO ashes will be returned
- Method of After Care

Enter coupon

Appointment Request Form

Methods of Aftercare

Payment Methods