Pet Euthanasia Request form (In home)

In Home Pet Euthanasia Request Form

Once submitted, you will be contacted within 24 hours. **If your pet needs a same day appointment, please call or text us 631-464-1410 before submitting this form. **
Client's Information*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
The above phone number is *
Preferred mode of communication:*

TextEmailPhone
Address where appointment will take place*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What date/time are you requesting for your appointment?*
Pet's Name *
Species*

DogCat
Pet's Breed*
Pet's Age *
Pet's approximate weight (This will be used for medication calculations and crematory charges)*
Pet's Gender*

FemaleSpayed FemaleMaleNeutered Male
Pet's Color/Markings*
Is your pet aggressive at the vet or at home?**
Please describe in detail. Please note that your pet may be denied services if Dr. Alana or her staff feel unsafe. A house call visit fee of $258 will be charged to owner for fuel driving time, and time spent in the home.
If your pet is over 30 pounds and you are requesting a cremation, is there someone in the home that is willing and able to help Dr. Alana bring your pet to her vehicle? (This will only be needed if Dr. Alana does not have an assistant with her at your appointment) *
Please briefly explain the circumstances/ illnesses leading up to your decision. Is your pet currently being treated for any medical conditions by a veterinarian?*
Dr. Alana does not perform euthanasia for behavioral reasons or convenience. Dr. Alana’s Veterinary Care reserves the right to deny services if deemed appropriate.***
When was the last time your pet was seen by your Veterinarian? *
Are you requesting a same day (within 24 hours)/weekend/ after hours or holiday appointment? If yes a $100 fee will be added at checkout*
Same day/emergency appointment requests are subject to availability.
Is your pet over 100 pounds? If yes an additional $195 will be added for crematory pick up and/or $100 for euthanasia*
Please advice if your pet is over a 100 pounds and a crematory pick up is not scheduled you will have the responsibility to transfer your pet to the crematory.
Please select which aftercare you would like**

No after care needed (Owner will be responsible for taking pet to crematory/cemetery)Communal cremation (No ashes returned to owner)Separate cremation (Ashes returned to owner)
Please add any personal requests for your pet or details about your home for your visit*
Please let us know where to park*
**If you have requested aftercare we ask you kindly leave a parking spot open close to your door in order for us to transport your pet from your home into our vehicle as safely and respectfully as possible
Dr. Alana's Veterinary care is unable to hold appointment spots. If you need to cancel your appointment within 24 hours there will be a $100 cancellation fee. I, the undersigned, do hereby certify that I am the owner (or duly authorized for the owner) of the animal described above. I do hereby give Dr. Alana Lauritano of Dr. Alana's Veterinary Care full and complete authority to euthanize and arrange the aftercare (If applicable) of said animal. I do also hereby certify that to the best of my knowledge the said animal has not bitten any person or animal during the last ten (10) days and has not been exposed to rabies.*
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Dr. Alana's Veterinary Care, P.C. I AM ACCEPTING RESPONSIBILITY AND LIABILITY FOR THE AFTERCARE AND LAWFUL DISPOSITION OF MY PET'S REMAINS AFTER EUTHANASIA. State, County, and local laws and ordinances may apply in regard to disposition of animal remains due the fact that the solution used in humane euthanasia is toxic and may cause death to wildlife and domestic animals, and leach into soil, contaminating groundwater. By signing below, I acknowledge that I am declining to have Dr. Alana's Veterinary Care, P.C. transport my pet for cremation or burial at a licensed pet cemetery. By doing so, I am accepting full and total responsibility for the lawful disposition of my pet's remains in accordance with all applicable statutes and ordinances; thereby relieving and absolving Dr. Alana's Veterinary Care, P.C. of all obligation, responsibility and liability related thereto.
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In Home Pet Euthanasia Request Form

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