The Visiting Vet Euthanasia Appointment Request Form

Euthanasia Appointment Request Form

Please fill out this form with your information and we will get back to you. If your request is urgent please email or call as well to ensure we have seen your message. NB. This is not an emergency service and if I am unable to attend you will have to be seen by a bricks and mortar practice in an emergency.
Your Details*

First NameLast Name
Contact Number
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are there any issues with locating your property? Please leave any relevant info here if so:
Parking is:

Readily available, on streetPlease park on the drivewayParking is by visitor permit which we will provideYou will need to pay to park here (meter parking, multi-storey etc)Other
What is your requirement at this stage?

I require an emergency appointment today, if available (PLEASE EMAIL, TEXT OR RING AS WELL AS FILLING OUT THE FORM)I require an urgent appointment over the next few daysI require an appointment, but it is not urgentI am registering in advance, I will be in touch when I need an appointmentI have already made an appointment, I'm just leaving you my detailsI am registering to receive information about your services for now, I don't need an appointment
How did you hear about us?

GoogleVet referralRecommendationOther
Pet's Details and Information
Pet's name
Species

CatDog
Pet's age or date of birth
Breed and approximate weight (if known)
Sex

MaleFemale
Neutered?

YesNo
What is the reason for euthanasia?
Has your pet had any Chemotherapy?*

YesNo
Is your pet difficult to handle or aggressive? NB. you must inform us before the appointment if your pet is aggressive or difficult to handle. We may need to visit in advance to dispense sedatives prior to euthanasia, and/or arrange to bring an assistant. *
Please confirm you understand we reserve the right to leave without refund if we are not told in advance of behavioural issues.*

I understand
What veterinary practice is your pet registered at? (if they are not, type N/A)
Would you like us to inform your usual practice of your pet's euthanasia?
Would you like us to obtain your records from your vets so we can review the notes before visiting?

YesNo, I would prefer notNot registered with another vet
Is your pet insured?

YesNo
If yes, who is your pet insured with?
This is a pay in advance/at the time service. How do you wish to pay for your appointment?

Bank transfer in advance (preferred)Cash at time of appointmentCard Payment at time of appointment (£5 transaction fee applied)
Afterwards
Please note: fees for cremation are in addition to euthanasia charges. PLEASE FOLLOW THIS LINK FOR CREMATION OPTIONS AND PRICING
What are your wishes for your pet's body after euthanasia?

Please will you arrange individual cremation through The Visiting Vet Company via PCS. Jess will take your pet with her. (ashes returned IN A SCATTER TUBE IN 7-14 days, no paw prints or hair clippings provided unless we are expressly asked)Please will you arrange individual cremation through The Visiting Vet Company via PCS. Jess will take your pet with her. (ashes returned IN A WOODEN CASKET WITH YOUR PET'S NAME ENGRAVED ON THE TOP IN 7-14 days, no paw prints or hair clippings provided unless we are expressly askedPlease will you arrange individual cremation through The Visiting Vet Company via PCS. Jess will take your pet with her. (ashes returned IN AN ALTERNATIVE VESSEL FROM THE PCS WEBSITE IN 7-14 days, no paw prints or hair clippings provided unless we are expressly asked)Please will you arrange individual cremation through The Visiting Vet Company via Harrogate Pet Crematorium (WEEKDAYS DURING WORKING HOURS ONLY). Jess will take your pet with her. (ashes returned IN A SCATTER TUBE WITHIN 7 DAYS), no paw prints or hair clippings provided unless we are expressly asked)Please will you arrange routine cremation through The Visiting Vet Company. Jess will take your pet with her. (NO ASHES RETURNED , no paw prints or hair clippings provided unless expressly asked)We will arrange our own cremation/home burial
Would you like us to take paw prints from your pet?*
Please confirm you understand this is not a 24/7 service - and out of hours, or when I am unavailable, you will need to visit a 'bricks and mortar practice' in an emergency*

I confirm
Data Protection: We will use the information you give us exclusively for the purpose of registering with The Visiting Vet Company*

Please Opt in to having your details held by us
Please read and agree to our Terms and Conditions and Privacy Policy
I agree to the terms and conditions and privacy policy
Please verify that you are human*
Should be Empty:

Euthanasia Appointment Request Form

Pet's Details and Information

Afterwards