Quality of Life Consultation

Quality of Life Consultation & Potential Euthanasia Intake Form:

Doctor Stanley understands how difficult this decision can be and will always provide an exam and consultation to discuss your pet's condition and quality of life before euthanasia is offered. While it is with a heavy heart that Dr. Stanley offers this service, he is grateful to be able to provide a peaceful transition for your pet in the comfort of your home. Euthanasia services are not available for behavior problems or minor, treatable ailments.
Urgency level

I need assistance today I need assistance in the next couple of days Not urgent, but it seems like my pet's time is limited
Client Information
Full Name *

First Name Last Name
Address for the house call: *

Street Address

Street Address Line 2

City

Postal / Zip Code
Phone Number *
Can you receive text messages? *

Yes No
E-mail *
example@example.com
Special arrival instructions/requests:
Gate codes, parking details, text on arrival, apartment and building numbers, etc.
Patient Information
Patient Name: *
Information regarding your pet's condition: *
Please provide a detailed description. The more information the doctor has the better.
Species: *
Breed/Type: *
For exotic animals, please be as specific as possible.
Color/Markings:
Sex: *
Approximate age or birthdate: *
Please include units, i.e. years, months, weeks
Approximate weight: *
Please include units, i.e. lb, oz, g
Previous records:

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Cancel of
Request for remains: *

I will keep the remains for home burial or make my own arrangements. I would like Dr. Stanley to take my pet for group cremation (no ashes returned). I would like Dr. Stanley to take my pet for private cremation (ashes returned).
Anything else you would like the doctor to know prior to the visit:
Should be Empty:

Quality of Life Consultation & Potential Euthanasia Intake Form:

Client Information

Patient Information