Cremation Authorisation

Southern Cross Veterinary Practice · Walvis Bay

We are sorry for your loss. This form lets you arrange your pet's cremation without paperwork — fill it in below and we will take care of the rest. If anything is unclear, phone us on 064-220036 and we'll help.

Your pet

Pet's name

Species Breed

What kind of animal?

Sex Weight

Estimated is fine if you're not sure.

Date of birth Date of passing

Microchip number (if any)

Your details

First name Surname

Phone Email P.O. Box Physical address SCVP account number (if known)

Ashes & box

Wooden box

No box ashes in cardboard box

Box colour

Black

Brown

White

Whitewash

Other

Describe the finish you'd like

We'll confirm options and price with you.

Plaque

No plaque

Silver

Black

Gold

White

Bronze

Other

Describe the plaque you'd like

We'll confirm options with you.

Words on the plaque

Please check the spelling carefully — the plaque is engraved exactly as written here. Emojis are welcome: 🐾 ❤ 🌈

Collection

Pick-up / drop-off Tell us what you'd like arranged Additional instructions (optional)

Authorisation

I hereby request Southern Cross Veterinary Practice to cremate the above-mentioned animal. I indemnify them against any claims of whatsoever nature arising from, or related to, the cremation of this animal. I acknowledge that I am indebted to them and am fully responsible for the payment of all costs.

I have read and agree to the above.

Type your full name as signature ID number

Your typed name and ID number, with the date and time of submission, serve as your signature.

Thank you — we've received your authorisation.

We'll be in touch to confirm the details. You don't need to do anything further.

PROTOTYPE — submissions are not live yet; nothing is sent.

Southern Cross Veterinary Practice · 151 Nangolo Mbumba Drive, Walvis Bay · 064-220036