Request Appointment Form

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Appointment Type
Euthanasia
Quality of Life Consultation
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Client Information* This field is required.
Name
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Phone NumberBy providing your phone number, you’re consenting to receive calls or SMS messages.
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I agree
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Email Address
example@example.com
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Client Information
Name
Phone Number
Email Address
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
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Laos
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Macau
Macedonia
Madagascar
Malawi
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Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
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South Ossetia
South Sudan
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Sri Lanka
Sudan
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eSwatini
Sweden
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Taiwan
Tajikistan
Tanzania
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Other
Country
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Level of Urgency
Please Select
Please Select
Within 24 hours
This Week
Undecided
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Reason for Euthanasia
Medical
Other
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Please Explain
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Pet Information
Pet's Name
Breed
Color
Weight
Please Select
Please Select
Male
Female
Sex
Please Select
Please Select
Yes
No
Spayed or Neutered
Primary Veterinarian
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We would like to gather some more information regarding your pet and their current medical circumstances. Completion of these next sections should take about 15-30 minutes. If you do not have time to complete at this time, please feel free to submit the appointment request now and we will be in touch with you as soon as possible.
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Is there anything else you would like us to know about your pet?
YESNO
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Please Explain
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After Care Wishes
Please Select
Please Select
Private Cremation
Communal Cremation
Home Burial
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Do you want to continue or submit the form?* This field is required.
Submit
Continue
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General Background
What made you reach out to us?
What are your goals for this appointment?
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What do you feel are your biggest challenges and unanswered questions at this point?
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Share with us your understanding of the disease process and what has been explained to you thus far with regards to “what is going on” with your pet.
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What treatment and/or management options for your pet’s disease have been offered to you?
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What are the signs/symptoms (if any) you are seeing now?
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Do you have any understandable financial considerations or physical/emotional/time limitations with managing your pet’s ongoing care?
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What medications/supplements is your pet currently receiving?
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Does your pet easily take medications?
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What is your pet’s current diet?
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Are you having to feed/encourage intake?
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Would you consider additional or continued diagnostics or simply manage your pets care based on symptoms alone?
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What are your “lines in the sand” with regards to “stopping points” in care?In other words, what don’t you want your pet to experience or what point do you not want your pet to get to? (e.g., if my pet’s pain cannot be controlled, when my pet can no longer get up by himself, when he no longer wants to engage with us as a family...)
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Do you have a preference between euthanasia or a natural death?
What are your previous experiences with euthanasia?
What concerns do you have around euthanasia?
Have you thought about the place you wish to have the passing happen? Who will be present?
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Do you wish to have a ceremony or ritual before or after the passing?
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Do you have plans for aftercare? Cremation vs burial
Should be Empty: