In home pet euthanasia request form

In Home Pet Euthanasia Request Form

Once submitted, you will be contacted within 24 hours. **If your pet needs a same day appointment, please call or text us 631-464-1410 before submitting this form. **
Owner's Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter your mobile number above.
Is this a cell phone or land line?
When are you requesting an appointment for?
Preferred mode of communication:*

TextPhoneEmail
Address where appointment will take place*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet's name:*
Pets species:*

DogCat
Pet's age *
Pet's Breed*
Pet's colors/markings*
Pet's Gender*

FemaleFemale SpayedMaleMale Neutered
Is your pet aggressive at the vet or at home?*
Please describe in detail. Please note that your pet may be denied services if Dr. Alana or her staff feel unsafe. A house call visit fee of $195 will be charged to owner for fuel and driving time, and time spent in the home.
Pet's approximate weight (This will be used for medication calculations and crematory charges) *
Weight will be used for drug calculation and for crematory charge if applicable.
If your pet is over 30 pounds and you are requesting a cremation, is there someone in the home that is willing and able to help Dr. Alana bring your pet to her vehicle? (This will only be needed if Dr. Alana does not have an assistant with her at your appointment) *
Please briefly explain the circumstances/ illnesses leading up to your decision. Is your pet currently being treated for any medical conditions by a veterinarian? *
***Dr. Alana does not perform euthanasia for behavioral reasons or convenience. Dr. Alana’s Veterinary Care reserves the right to deny services if deemed appropriate.***
Current Veterinarian's name and phone number: *
When was the last time your pet was seen by your Veterinarian? *
Please choose your preferred arrival time below. Due to the nature of being a mobile practice serving most of Suffolk County, we can not give exact appointment times. Therefore, our appointments are made as 4-5 hour time slots.

Your estimated arrival window begins at the time you select, e.g.:

(11am appointments - estimated arrival time is 11am-5pm).

(12pm appointments - estimated arrival time is 12pm-6pm).

(1pm appointments - estimated arrival time is 1pm-7pm).

(2pm appointments - estimated arrival time is 2pm-7pm).

(3pm appointments - estimated arrival time is 3pm-8pm).

(4pm appointments - estimated arrival time is 4pm-8pm).

We will contact you when we are on our way to you; usually about a half hour before we will arrive.

While we strive to be timely, in the case of an emergency or other unforeseen circumstance, we may need to ask you to adjust your appointment time. Please know that we only do this as necessary, and ask for your understanding, as we would do the same for your pet.
Are you requesting a same day (within 24 hours)/weekend/ after hours or holiday appointment? If yes a $100 fee will be added at checkout. *
Same day/emergency appointment requests are subject to availability.
Is your pet over 120 pounds? If yes an additional $195 will be added for crematory pick up.
If you would like, please upload a photo of your pet

Cancelof
Please select which aftercare you would like*

No aftercare neededPrivate Cremation (ashes returned)Communal Cremation (no ashes returned)
If choosing private cremation, please select urn from above photos.

Decorative Metal Urn- BlueScattering TubeBamboo Box UrnCedar Memorial UrnHand Carved RosewoodSerenity Urn (additional $30 upgrade, please choose at checkout)
How did you hear about us?*

Facebook groupFacebook adGoogle searchFriend/ FamilyOther
Name of Friend/Family who referred you: (if applicable)
Please add any personal requests for your pet or details about your home for your visit:
Please let us know where to park: *
**If you have requested aftercare we ask you kindly leave a parking spot open close to your door in order for us to transport your pet from your home into our vehicle as safely and respectfully as possible.
Dr. Alana's Veterinary care is unable to hold appointment spots. If you need to cancel your appointment within 24 hours there will be a $100 cancellation fee. I, the undersigned, do hereby certify that I am the owner (or duly authorized for the owner) of the animal described above. I do hereby give Dr. Alana Lauritano of Dr. Alana's Veterinary Care full and complete authority to euthanize and arrange the aftercare (If applicable) of said animal. I do also hereby certify that to the best of my knowledge the said animal has not bitten any person or animal during the last ten (10) days and has not been exposed to rabies.*

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Date*

MonthDayYear
Date
Please read and sign if no aftercare is chosen above.
Dr. Alana's Veterinary Care, P.C.

I AM ACCEPTING RESPONSIBILITY AND LIABILITY FOR THE AFTERCARE AND LAWFUL DISPOSITION OF MY PET'S REMAINS AFTER EUTHANASIA.

State, County, and local laws and ordinances may apply in regard to disposition of animal remains due the fact that the solution used in humane euthanasia is toxic and may cause death to wildlife and domestic animals, and leach into soil, contaminating groundwater.

By signing below, I acknowledge that I am declining to have Dr. Alana's Veterinary Care, P.C. transport my pet for cremation or burial at a licensed pet cemetery.

By doing so, I am accepting full and total responsibility for the lawful disposition of my pet's remains in accordance with all applicable statutes and ordinances; thereby relieving and absolving Dr. Alana's Veterinary Care, P.C. of all obligation, responsibility and liability related thereto.
Signature

Clear
Date*

MonthDayYear
Date
My Products*
Categories:All

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Crematory Pick Up Pets over 100 pounds must have the crematory pick up. Dr. Alana will arrange for the crematory staff to meet her at the appointment or as soon as possible to transport your dog from your home to the crematory.
$185.00



In home euthanasia for pets under 20 pounds. (no aftercare)
$480.00 Quantity



In home euthanasia for pets 20-39 pounds (no aftercare)
$505.00 Quantity



In home euthanasia for pets 40-59 pounds (no aftercare)
$555.00 Quantity



In home euthanasia for pets 60-89 pounds (no aftercare)
$590.00 Quantity



In home euthanasia for pets 90-120 pounds (no aftercare)
$695.00 Quantity



In home euthanasia with private cremation for pets up to 20 pounds
$844.76 Quantity



In home pet euthanasia with private cremation for pets 20-49 pounds
$892.78 Quantity



In home pet euthanasia with private cremation for pets 50-89 pounds
$989.93 Quantity



In home pet euthanasia with private cremation for pets 90-120 pounds
$1,089.93 Quantity



In home pet euthanasia with communal cremation for pets up to 20 pounds. (no ashes back)
$578.62 Quantity



In home pet euthanasia with communal cremation for pets 20-49 pounds (no ashes back)
$598.62 Quantity



In home pet euthanasia with communal cremation for pets 50-69 pounds (no ashes back)
$670.21 Quantity



In home pet euthanasia with communal cremation for pets 70-120 pounds
$730.21 Quantity



Additional Paw print
$38.00 Quantity



Pets over 120 pounds please add
$100.00 Quantity



Serenity Urn (Upgrade)
$30.00 Quantity



SAME DAY APPOINTMENT (within 24 hours of request)
$100.00 Quantity



Weekend, evening (after 5pm) or Holiday request
$100.00 Quantity



Total

$0.00
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Once your from is filled out we will get back to you within 24 hours. At that time an appointment will be made of available and an invoice will be sent to your email for the selection you made above. Invoices must be paid for your appointment in order to be confirmed.
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In Home Pet Euthanasia Request Form

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