CompassionVet Patient Intake Form

In Home Euthanasia Appointment Request Form

Euthanasia for pets is a heart-wrenching choice. We hope to grant them a gentle passage, surrounded by the love they've known in the comfort of their home, sparing them further pain and ensuring their comfort until the very end. If you are uncomfortable filling out the form, please text or call us at 850-888-4229 and we will respond as soon as possible.
Your Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Secondary Phone Number
Please enter a valid phone number.
Email*
example@example.com
Pets Name *
Pet's Date of Birth

MonthDayYear
Date
Species*
What breed is your pet?
Approximate weight of your pet in pounds*
Who is your pet's veterinarian/ Which hospital do they go to for wellness services? *
Is your pet fearful, aggressive, and have they ever bitten anyone? Please explain. *Note: we cannot euthanize a pet that has bitten a person within the last 15 days*
All services are by appointment only. Which day(s) are preferable for you?*

MondayTuesdayWednesdayThursdayFridayNo Preference
Which after care option are you interested in?

Private Cremation: Includes certificate of cremation, premium sheesham urn, urn nameplate (pet's first name), and a clay paw print. Your pet's ashes will be mailed to you.Communal Cremation: Your pet's ashes will be spread over a beautiful gardenI will keep my pet's remainsUnsure
Would you like our veterinary staff to wear a mask during the appointment?
I agree to the following:*

In order to keep everyone safe, if my pet is aggressive, I agree to a brief examination for oral sedative medications with CompassionVet or with my pet's primary care veterinarian prior to the humane euthanasia appointment. This will help to ensure safety and will decrease your pet's stress. If aggressive behavior causes our staff to feel unsafe, we reserve the right to reschedule, cancel, or discontinue an appointment at any time. If any other pet in the household is aggressive, they will be secured.If I choose cremation for my pet over 20lbs, there will be at least one person available to help carry my pet to the car unless otherwise arranged with us. If my pet is over 50lbs, there will be at least 2 people to help carry my pet to the car (Dr. O'Brien has an injury and a lifting restriction of 20lbs)My pet has not bitten anyone in the past 15 days
This will be an in-home veterinary visit. Please have your pet ready at the designated appointment time. We will contact you when we are on our way. If you need to reschedule, please contact us at least 24 hours prior to your scheduled appointment time. All payments are due at time of service.

I Agree
Should be Empty:

In Home Euthanasia Appointment Request Form