Pet Euthanasia Request

Owners Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Number

Email Address

example@example.com

Pet's Name

First NameLast Name

Does your pet have a nickname?

First Name

Pet's Breed

Pet's Approximate Weight

What is your pet's gender?

Pet's Age

Who is your pet's regular veterinarian?

Veterinarian's phone number?

Is your pet currently taking any medications. Please list.

Is your pet aggressive? If so, please describe

Would you like us to inform your veterinarian of the death?

YesNo

What is your pet's current diagnosis?

Have treatment option(s) been employed?

What date would you like to bring your pet in?

All dates are subject to doctor availability.

Morning or afternoon?

Location of Euthanasia

Your HomeCremation CenterSomewhere else

Aftercare or Disposition

CremationHome BurialBurial in a perpetual care cemeteryOther

How did you hear about our services?

What will be involved in euthanasia of my pet?

Columbia Pet Euthanasia Services (CPES) understands the deep relationship you have with your pet. We appreciate that your decision to euthanize your pet has not been made lightly, and we know that the day and the time of the euthanasia of a beloved pet is emotion-filled. That’s why we like to explain what is expected to happen ahead of time, and will also explain and answer any questions you have on that day.

If your pet will be euthanized in your home, CPES will keep you informed of the arrival time and notify you if difficulties cause a delay beyond the promised window of time for your appointment. Upon arrival at your home, the veterinarian will join you (with any family and friends present) in the spot that you provide where they can observe and briefly examine your pet. If you are interested in sharing, they love to hear a story about your pet in happier times.

They will describe the planned steps in the euthanasia process, as follows: A sedative is provided, usually by injection or possibly orally. If injected, a tiny needle is used and occasionally the pet feels a small stinging sensation, especially if there is increased sensitivity due to chronic pain. You may choose to talk to and “love on” your pet during the time that the sedative is taking effect (about 10 minutes). Once sedated, your pet will be fully asleep. Occasionally small reflex movements such as stretches or breaths are observed, and these are not due to stress.

Euthanasia solution is then administered, usually intravenously. It is common, however, that a vein is not accessible, which may be due to the pet’s physical condition. When that occurs, the veterinarian will explain the need to choose to use an alternate (internal) route and, in some instances, may draw up a bit more euthanasia solution. Your pet is not feeling any discomfort should this alternate route be used to help your pet to pass peacefully.

All of us at CPES want the euthanasia experience to be calm and soothing for you and especially for your pet. Thank you for allowing us to help you during this difficult time.

Our veterinarians follow euthanasia guidelines including those promoted by the American Veterinary Medical Association, Companion Animal Euthanasia Training Academy, and the American Association of Feline Practitioners. We are happy to provide any references for you for further study or information.

I acknowledge that I have read and understand the information above. (Required)

Yes

I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above, that I do hereby give veterinarians Dr. Brian Ortman or Dr. Charlotte Krugler and his/her employees or representatives, full and complete authority to end the life of said animal.

I acknowledge that Dr. Brian Ortman or Dr. Krugler, will meet at the time of the appointment to discuss the euthanasia of my animal. I also certify that to the best of my knowledge the said animal has not bitten any person or animal during the last fifteen (15) day and has not been exposed to rabies. I further understand that I assume financial responsibility for all services rendered. Again, by signing this form I am giving permission to end this animal’s life, and I have the authority to carry out this consent.

I acknowledge that I have read and understand the information above. (Required)

Yes

Signature

Please verify that you are human*

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