Euthanasia Consent Form
We understand this is a difficult time. This information will help us provide the best care possible. Please fill out what you are able. If you are struggling, we have starred required questions, or you may reach out to us for assistance.
Full Name
First Name
Last Name
First Name
*
Last Name
*
Phone Number
*
Please enter a valid phone number.
Email
*
AtPeaceBCS@gmail.com
Home address (location of appointment)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please let us know if your mailing or home address are different from provided appointment address.
Please tell us a bit about your pet
Pets name
*
Species
Dog
Cat
Another species
he/she
him/her
his/her
Breed
Age
If you're not sure about the exact age, an estimate is fine!
Approximate weight (in pounds)
*
Disposition
*
My pet is friendly, loves all guests and strangers, and has never shown aggression
My pet is a bit timid, and will take some time to warm up, but has never shown aggression towards people
My pet has shown aggression in the past, or may be unpredictable in this difficult situation. Please contact me in advance to discuss how to make this the most comfortable experience possible for everyone involved.
Medical issues
Please tell us more about what you and your pet are going through.
Primary Veterinarian
Please tell us more about your beloved pet and submit a photo of them:
Their personality, how they were in life, habits, etc.
File Upload
Browse Files
Drag and drop files here
Choose a file
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of
Aftercare
Desired aftercare
*
Please Select
Private Cremation (ashes returned to you)
Communal Cremation (ashes scattered)
Home Burial (pet stays with owner)
If you are undecided, it is ok to change this later.
Please select an urn
I would like to select my own urn and/or add customization (additional costs will apply)
Blue scattering tube (cardboard)
Cedar memorial urn
Decorative metal urn - blue
Decorative metal urn - tan
Fond Memories vase urn - white
Fond Memories vase urn - black
Hand-carved rosewood urn
Satin bag
Remembrance urn
Serenity photo urn
Sitting cat urn - white
Sitting cat urn - black
For wooden urns, please customize your engraving plate. Text can be up to 3 lines, with 30 characters per line.
For the metal & ceramic urns, a heart charm will be engraved to hang on the urn. Please select 12 characters.
Appointment Planning
Appointment, timing, or other concerns
Please let us know if you have any special wishes or concerns regarding the appointment
Additional family members &/or pets that may be present at the appointment:
Will you or someone in your home be able to assist the doctor in carrying your pet to the car after the appointment?
Yes
No
No, but we can ask a friend or neighbor to assist when it is time.
Payment
"Angel Wings"
Cremation
Were additional fees mentioned during the scheduling process?
No
Yes, this will be an after hours appointment
Yes, it will be a holiday
Yes, assistance may be needed to transport my large pet
Yes, I live outside the service area (>20 min from Bryan - total here will be approximate)
Other
After hours
Driving
Holiday
Additional costs associated with your custom urn cannot be determined at this time. Please work with At Peace BCS to make a selection and you will be provided with a cost when available
Please indicate how you would like to pay for your appointment. Providing payment information upfront will help us avoid paperwork at the appointment. If you would prefer to pay cash or use a check, please have it ready at the start of the appointment.
*
Credit card entered here
Venmo (agree to friends and family payment)
PayPal (agree to friends and family payment)
Zelle
Check in home
Cash in home
Other
Estimated total
This estimate includes in-home service, cremation, and known additional charges. Inaccuracies in form completion may cause miscalculations.
Please enter your PayPal, Venmo, or Zelle information, to receive a payment request after your appointment. Additional fees will be charged if process as a business payment.
Credit Card Processing - you will not be charged until the appointment has been completed
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USD
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Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
COVID-19 protocol: Due to the current worldwide disease concern, please read the following: The doctors are fully vaccinated for your safety. They check their temperature every morning and will cancel your appointment if they develop any COVID symptoms, have an exposure, or test positive. Your safety is important to us. We do understand that it is difficult to cry in a mask, and do not require you to wear one for appointments. Please let the doctor know if you would like them to wear a mask or practice any additional safety precautions. Please check all statements that you agree to uphold.
*
No one in our home has a fever
No one in our home has any symptoms of COVID-19
No one in our home has tested positive for COVID-19, or been exposed to anyone who has tested positive for COVID-19 within the past 14 days.
Should any of the above information change prior to our appointment time, we will contact At Peace to delay our appointment.
Euthanasia Consent
I certify that this pet has not been exposed to any animal that is likely to have rabies; has not bitten any person or animal within the past ten days; and is current on his/her rabies vaccine.
I certify that I am the legal owner or authorized agent for the owner of the animal/pet described above, and do herby give At Peace BCS, and any authorized agents, staff, or representatives, full and complete authority to euthanize and care for my pet's body in a humane manner. I hereby forever release and hold harmless At Peace BCS, and any authorized agents, staff, or representatives from any and all liability for euthanasia and care of my pet's body. To the best of my knowledge, the information I have provided is accurate and complete. I understand that, with the guidance of a veterinarian, euthanasia will be carried out upon my signing this agreement, ending the life of my pet. 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 these provisions above.
*
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We operate an Angel Fund, which allows us to provide in-home services to families in need. If you would like to make a donation in your pets name, please provide an amount below.
Donations of $150 or higher will be matched by AtPeaceBCS to provide free services to a family.
Gender
*
Female
Male
Should be Empty: