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 Name
Last Name
Contact Number
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / 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 street
Please park on the driveway
Parking is by visitor permit which we will provide
You 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 days
I require an appointment, but it is not urgent
I am registering in advance, I will be in touch when I need an appointment
I have already made an appointment, I'm just leaving you my details
I am registering to receive information about your services for now, I don't need an appointment
How did you hear about us?
Google
Vet referral
Recommendation
Other
Pet's Details and Information
Pet's name
Species
Cat
Dog
Pet's age or date of birth
Breed and approximate weight (if known)
Sex
Male
Female
Neutered?
Yes
No
What is the reason for euthanasia?
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?
May we obtain your pet’s medical history from your current vet?*
Yes
No, I would prefer not
Not registered with another vet
Is your pet insured?
Yes
No
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 appointment
Card Payment at time of appointment (£5 transaction fee applied)
Afterwards
Please note: fees for cremation are in addition to euthanasia charges.
What are your wishes for your pet's body after euthanasia?
Please will you arrange with Wharfedale Pet Cremations for individual cremation with them, subject to availability - collection from and return to your house by the crematorium (ashes returned, paw prints and hair clippings, return of ashes within 48 hours where possible)
Please will you arrange with Wharfedale Pet Cremations for individual cremation with them, subject to availability - I will take my pet to the crematorium myself (LS21 2QP) (ashes returned within 48 hours where possible, paw prints and hair clippings arranged)
Please will you arrange individual cremation through The Visiting Vet Company (pets under 20kg only), subject to availability. Jess will take your pet with her. (ashes returned within 7 days where possible, no paw prints or hair clippings provided)
Please will you arrange routine cremation through The Visiting Vet Company (pets under 20kg only), subject to availability. Jess will take your pet with her. (no ashes returned, no paw prints or hair clippings provided)
I will arrange cremation or home burial myself
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
*
Submit
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