Midvalley Animal Clinic Euthanasia and Cremation Form

Your Name

First NameLast Name

Phone Number

Area CodePhone Number

Alternative Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet's Name

Species

All end of life procedures require an office visit. The doctors at Midvalley Animal Clinic will only euthanize for medical reasons and that I may be asked to present records if my pet has been seen elsewhere prior to services being performed.

Would you like to be present for the euthanasia procedure?

Date of your appointment

Date

Time of your appointment

:HourMinutesAM/PM Option

Please understand space is limited

We understand the decision to euthanize your pet is one of the hardest decisions you will ever have to make. We wish to make this experience as comfortable as possible for both you and your pet. Please don't hesitate to ask us any questions you may have.

Here's what to expect:

In order to administer the euthanasia solution, the veterinarian must gain entry into a vein. The euthanasia solution is specially made to act quickly and painlessly, but it is typically administered intravenously. We want to achieve this as peacefully and humanely as possible. This requires that your pet be calm. If your pet is uncooperative, defensive, afraid or even fractious, the veterinarian will not be able to properly carry out the euthanasia procedure and can end in a very uncomfortable experience for all. To avoid this, a technician will provide your pet with a sedative. The sedative comes in injectable form and will be given under the skin. Some pets find the injection causes a mild stinging sensation. If it does, it lasts only seconds. The sedative can take up to 10 minutes to take effect. Your pet will get tired and eventually lay down to go to sleep. During that time, the technician will leave you to be with your pet and will come back periodically to check in until your pet is completely sedated.

Some veterinarians ask that an IV catheter be placed before the procedure to allow them an open port into a vein to administer the medication. This is not always necessary. If the veterinarian requests an IV catheter for your pet the technician will place it. Please note, some animals (especially senior and/or ill) can have frail veins which may require more than one attempt to place the IV catheter. Our goal is to make this process as comfortable and humane as possible. Your pet will not feel anything while sedated. However, if you prefer not to be present for this, please inform your technician and they will make arrangements with you.

Once the IV catheter is placed, the technician will send in the veterinarian. You may wish to hold your pet in your arms at the time of euthanasia. The veterinarian will try to accommodate your wishes, but remember that it is imperative that the solutions be injected within the vein for the procedure to unfold properly and this may require a certain positioning in order to do so.

Usually within seconds after the solution is injected, your pet will take a slightly deeper breath, then grow weak and finally lapse into what looks like a deep sleep. Your pet, although completely unconscious, may continue to take a few more breaths before all movement ceases. The veterinarian will then listen with a stethoscope until your pet's heart stops. You may choose to spend a few moments alone with your pet after the procedure. We will leave the room to allow you to do so.

If you have arranged to take your pet home with you after, please make sure to bring a container or plan a location lined with non-absorbable material in your vehicle to receive your pet. The technician will usually place your pet into the container and will have someone help carry your pet out to your car for you. Please let us know if you wish to do this on your own.

If you wish to have your pet cremated through our cremation services, please complete the form below. Make sure to answer all questions pertaining to the options available. If you would like more information about your pet's cremation, please visit Pet Reflections. **Note: We do not offer more options than what is avialble on the form below.

Suggestion: You may want someone to be with you after the euthanasia appointment to drive you home. You may be surprised how difficult it can be to concentrate on driving after undergoing such an emotional event.

**Pricing is based off your pet's weight and may be adjusted when in clinic**

Aftercare options:

Private cremation - Your pet will be cremated individually from other pets and returned to you in a wooden urn of your choice.
Group Cremation - Your pet will be cremated with other pets and not returned to you.

Aftercare Options

You have arranged to take your pet home with you after, please make sure to bring a container or plan a location lined with non-absorbable material in your vehicle to receive your pet. The technician will usually place your pet into the container and will have someone help carry your pet out to your car for you. Please let us know if you wish to do this on your own.

Urn Type:

Choose a color of velvet bag:

This will be the bag that contains the cremains inside the wooden urn

Would you like to have the wooden box engraved for an additional fee of $60 (this includes two lines - Examples below)? For best results limit 35 characters per line.

Line #1 (Type exactly as you want it engraved including capital letters, dashes, etc.)

Example: Mr. Bigglesworth

Line #2 (Type exactly as you want it engraved including capital letters, dashes, etc.) If you do not wish to use the 2nd line, type, "Use line 1 only"

Example: 1/1/10 - 1/1/20

Would you like to add additional lines ($35 per additional line)?

Line #3 Additional $35 (Type exactly as you want it engraved including capital letters, dashes, etc.)

Example: 1/1/10 - 1/1/20

Choose a font above

Select a scroll to have engraved (included in the engraving fee):

Scrolls can be engraved on the urn. See picture above for examples.

The paw prints are hand crafted and hand painted with care and tenderness from start to finish by a company called Pet Reflections. Each paw print is made from your pet’s unique paw impression. Available for dogs, cats, birds, reptiles and exotic Pets. Paw prints are available with private or group cremations and can be done using ink on cardstock paper or as an impression on a glazed clay ornament.

Turn Around Time:

Because the ceramic paw prints are handmade they can take up to 2-3 weeks to be returned to the clinic. We will contact you when the print has arrived. Please feel free to contact us for an update or if you have any questions.

Would you like to order a ceramic or ink paw print?

Please select which you would like to purchase (you can select multiple):

Which paw would you like to be used for the print:

Choose the color of the print:

How many ? PLEASE NOTE: If you would like more than 1 paw print the price will increase. You can estimate the price by multiplying the amount of paw prints by the price above.

how many ceramic paw prints do you want?

Would you like to purchase a stand for the paw print?

I understand that the ink print may look different than the examples and can only be done in black ink.

How many ? PLEASE NOTE: If you would like more than 1 paw print the price will increase. You can estimate the price by multiplying the amount of paw prints by the price above.

How many ink paw prints do you want?

By signing below:

I hereby certify that I am the legal and rightful owner of the pet listed in this form and I am authorized to make end of life decisions.

Midvalley Animal Clinic is required, by Utah state law, to notify animal control if my pet has bitten someone within the past 10 days and that my pet might be required to complete a quarantine prior to euthanasia. I hereby certify that my pet has not bitten anyone within the last 10 days.

I forever release the staff and veterinarian from any and all liability of the said euthanasia.

I understand that Midvalley Animal Clinic is not responsible for any items left behind with my pet, for example: collar, sweater, leash, blanket, etc. I agree to take all items I wish to keep with me prior to leaving the clinic.

I understand that Midvalley Animal Clinic does not offer a payment plan and agree that this procedure is to be paid in full at the time of service. I understand that Midvalley Animal Clinic accepts cash, credit card, debit cards, and checks as forms of payment.

I authorize Midvalley Animal Clinic and all veterinarians, veterinary assistants, and staff therein to euthanize the animal I have listed on this form.

Signature

Midvalley Animal Clinic Euthanasia and Cremation Form

Cremation Information

Urns Options

Cedar Box Urn

Alder Box Urn

Maple Box Urn

Redwood Box Urn

Personalized Last Engraving

Scroll #1

Scroll #2

Scroll #3

Paw Print Options

Ceramic Paw Prints

Black Ink Paw/Nose Prints

Authorization and Consent to Euthanize