Client Name
First Name
Last Name
Pet Name
What is your overall goal of care for your pet? What are we aiming for?
What is the most import thing to you when considering your pet's treatment?
Treatment Plan Considerations
There are many factors to consider when developing a customized treatment plan for an ill pet. Pet personality, family preferences, and resources (emotional/physical/financial/time) all need to be included. Answering the next few questions helps us paint a picture of your family's unique situation.
What treatment options or therapies have been offered to you for your pet's condition?
How easy is your pet to medicate? What struggles are you having administering their current medications?
Are you comfortable with injections? Would you be open to learning how to administer injections to your pet?
Future Diagnostics
I do NOT want further diagnostics and prefer to monitor my pet by outward symptoms alone.
I am open to in-home diagnostics ONLY (bloodwork, blood pressure, needle biopsies).
I am open to taking my pet to my primary care vet for imaging/tests (x-rays, ultrasound, etc)
I am open to taking my pet to a specialty center for advanced imaging/tests (CT, MRI etc)
At this time, how concerned are you about the following things
Not concerned
Somewhat concerned
Actively concerned
My pet suffering
My pet dying alone
Not knowing the right time to euthanize
Desire to perform nursing care for my pet
Ability to perform nursing care for my pet
Coping with their loss
Concern for other members of the family (ie: children)
How often and for how long is your pet left unattended? Is there future travel planned in the near future?
Do you have any understandable financial considerations with managing your pet's ongoing care?
Planning Ahead - Farewell Care
The next few questions focus on your pet's end-of-life. While difficult, reflecting on these questions allows us to prepare for their passing and to hopefully achieve a peaceful farewell. Feel free to leave answers blank if you are unable to answer at this time.
What are your thoughts about euthanasia?
What instances would you consider to be the appropriate time for euthanasia:
YES
No
If they are feeling pain?
If they can no longer urinate and/or defecate on their own?
If they start to experience seizures?
If they become violent beyond control?
If they have stopped eating?
If they are no longer acting like themselves?
If they have a condition that will only worsen with time?
If the veterinary team recommends euthanasia?
If financial limitations prohibit treatment?
What are your plans for your pet's remains?
home burial, cemetery burial, private cremation, etc.
Please add any concerns or comments not addressed above?
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