Name* First Last Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Relationship to the Pet*Pet's Name*Payment Method Cash Check Credit Card - 3.75% Processing Fee Credit Card Pickup Location Home Pickup - May be additional personnel fee for pickup of larger pets Customer Bringing pet in Pet is at Veterinary Office Pet's WeightPickup Date MM slash DD slash YYYY Pickup Time : Hours Minutes AM PM AM/PM Base Price: $375.00This field is hidden when viewing the formPickup Type Standard After Hours Weekend Large Pet Pickup SurchargeAfter-Hours SurchargeWeekend SurchargeSubtotal Price: $0.00 CC Fee Price: $0.00 Total $0.00 Authorization I Agree By checking the above box, I hereby request and authorize Hindman Funeral Homes & Crematory, Inc. and affiliates (Hindman) to transfer the deceased pet into their care. I represent that I am the legal owner of the deceased pet or have the authority in matters pertaining to the disposition of the deceased pet and have selected cremation. I acknowledge that charges apply from the initial transfer of the deceased pet into Hindman’s care and agrees to pay the applicable service fee as calculated below for the individual cremation which also includes the transportation and basic pawprint urn. I acknowledge that after hours or weekend rates could apply. CAPTCHA
