Consent Form for In-Home End-of-Life Services

Your Full Name:

First Last

Appointment Date:

Date

Address (additional travel fee applies to locations beyond standard service radius)

Address

Street Address Line 2

City/State

Zip

Email Address:

example@example.com

Home Phone:

Pet's Name:

Species (Dog, cat):

Female or Male:

Breed:

Color:

Age:

Weight (approximation is okay):

Primary Veterinary Clinic/Hospital and Veterinarian:

How did you learn of us?:

Are there any special considerations for your visit? Is there anything you'd like for the doctor to know prior to arrival? (ie, text instead of ringing bell, my pet does not like strangers, etc)

Aftercare Arrangement Options

I would like Private Cremation service for my pet. My pet's ashes, and only my pet's ashes, will be returned to me. I will be notified when my pet's ashes are available to be picked up from Hinsdale Pet Memorial Services. The standard urn option will be chosen unless I elect a different urn choice (see link on website).I would like Memorial Cremation service for my pet. I do not wish for my pet's ashes returned to me. Ashes will be scattered over cemetery grounds at Hinsdale Pet Memorial Services.I do NOT wish to have Faithful Friends Home Vet arrange for my companion animal's aftercare. I will handle and take full responsibility for all after care arrangements myself.  I am aware of any applicable laws and regulations regarding the burial of my companion animal’s body and understand caution should be taken when disposing of animals euthanized with drugs/chemicals. I understand that laws and significant fines exist for improper burial as well as for unintentional death of wildlife and protected species.

I would like a clay paw impression (one included if desired). Additional impressions available for $25 each.

YesNo thank youOther

I certify I am the legal owner/duly authorized agent for the owner of the companion animal described above and give Faithful Friends Home Vet and any authorized agents, staff, or representatives full and complete authority to euthanize and dispose of my companion animal in a humane manner. I forever release and hold harmless Faithful Friends Home Vet and any authorized agents, staff, or representatives from any and all liability for euthanasia and disposal of my companion animal.Dogs, Cats and Ferrets: To the best of my knowledge, the dog, cat or ferret described above has not bitten, scratched and/or potentially exposed any person or other animal to rabies in the past ten (10) days. Other Species: To the best of my knowledge, the animal described above has not bitten, scratched and/or potentially exposed any person or other animal to rabies in the past thirty (30) days. I understand that if the animal described above has bitten or otherwise potentially exposed any person within the time specified, a rabies test must be performed.I understand euthanasia is the act of ending the life of an animal in a painless way to prevent unnecessary suffering. To the best of my knowledge, the information I have provided is accurate and complete. I understand my wishes may be carried out immediately upon my signing this agreement. Fees for these services have been explained to me, and I assume full responsibility for all charges applicable to such services. I have carefully read and fully understand the foregoing provisions.

YesNo

COVID-19 Screening: Have you been exposed to any person with COVID-19 or COVID-19 symptoms in the past 14 days?

YesNo

Have you, or any person in the home, experienced illness, fever, or respiratory symptoms in the past 14 days.

YesNo

I agree to the following: All present during in-home services will a wear a fitted mask(s) and adhere to social distancing guidelines to the best of our abilities. Visits are to be held outdoors (porch, yard, open garage). If inclement weather or pet’s medical condition warrants, we may discuss indoor visit to be limited to just within the entry to the home. We understand that this is to protect our health as well as the health of the visiting veterinarian and our entire practice clientele.

YesNo

Fees will be based on the following:

In-Home Euthanasia Services $400

Memorial Cremation (no return of ashes) $0

Private Cremation with Return of Your Pet's Ashes $200

Weekend or after 5pm $50

After 7pm $100

Pet over 85 pounds $50

Pet over 100 pounds $75

Pet over 150 pounds $100-$150

Travel beyond service radius $50-$150

Standard Urn or Eco Urn $0

Other Variety of Urn or Memorial Jewelry $ Variable

Urn Engraving $30-$50

Clay Paw Impression $25

Painted Paw Print $75

3D Paw Print $95

Is there anything you would like us know about your preferences for aftercare arrangements? (For example: "We would like X number of paw impressions" or "We would like the Odyssey Urn engraved with our pet's name in script font". It is ok if you do not know yet. All can be decided later as well.)

Form of Payment

*We will pay by check/cash at time of visitWe would like an electronic invoice prior to our visit

Owner/Agent Signature