About Albany NY Mobile Veterinarian Roger Blankfein

Pet's Name *

First Name *

Last Name *

Partner/Spouse full name

Best Phone *

Mobile phone if "best" phone is not mobile

Email *

Confirm Email *

Physical Address *

Physical Address

City

State/Province

Zip/Postal

Physical Address is: *

Physical and Mailing

Physical only

Mailing Address *

Mailing Address

City

State/Province

Zip/Postal

Primary Care Veterinary Hospital *

Affirmations and Declarations

Medical Decisions *

I am authorized to make medical, euthanasia, and body aftercare decisions for the above referenced pet.

Euthanasia Request *

I authorize and request euthanasia for the above referenced pet.

Pet's Biting History *

Yes, this animal has bitten a person or animal in the past ten (10) days.

No, this animal has not bitten any person or animal in the past ten (10) days.

Body Care Options

Body Care Options *

Private Cremation

Group/Communal Cremation

I Will Keep the Remains

Keeping the Remains *

I will keep the remains for burial or other arrangement in accordance with local ordinances for environmental and wildlife safety. I understand that medications used are toxic to other animals including wildlife and groundwater.

Group/Communal Cremation *

I understand that the ashes will not be returned to me.

Private Cremation *

I will pick up the ashes at Corner Gateway Business Service Center, 1972 New Scotland Road, Slingerlands, NY 12159 (no additional charge)

UPS delivery directly from cremation provider ($30 fee). (signature required upon delivery)

Visiting Doctor *

Please indicate the doctor with whom you have scheduled an appointment.

Today's Date

Signature

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Euthanasia/Body Care Authorization and Medical Record

Affirmations and Declarations

Body Care Options

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