Compassionate Home Euthanasia Appointment Request Form
Helping Your Furry Family Member Pass Peacefully at Home
Preferred date and time
*
Would you like:
Quote only with afterhours noted if required (no specific day or time )
To Book an appointment
Both (tentatively book and send pricing)
VIP name (Very Important FurryPerson)
*
Microchipped?
*
no
yes
Microchip number (if known)
Breed
*
Colour of Furry Person
*
Weight
*
Age
*
Female (F) Male (M)
*
Eating? Y/N
*
Vet Referral (if applicable) Please include name and contact
Please Select
OPTION 1 - Give referring vet information
OPTION 2 - No examination
OPTION 3 - Chat about history & gentle examination
Contact number of referring vet
How did you find with us?
Friend/family
Facebook
Google
Vet referral
Other
If someone referred you, who can we thank?
Other furry/Fluffy people (other pets that will be present)
*
Address
*
Back
Next
Children connected to VIP (for card so they feel included)
Hooman family name/s (First &surname)
*
Mobile number
*
Email (must be active, as it will be used to send important information)
*
Vet clinic, favourite vet & nurse
Reason for euthanasia
Please choose one: OPTION 1 – YOUR ARE NOT 100% sure about timing and would like me to get records from vet incase there is another possibility. OPTION 2 – YOU KNOW ITS THE RIGHT TIME for your furry family & for a gentle examination (Aus Vet Law says we must) during our consult to verify timing is best as the only hope now is for a peaceful passing
*
OPTION 1
OPTION 2
If Option 2: Is there anything specific you would like us to check?
Would you like help organising cremation services?
Yes
No
Please provide your vet clinic contact details
If Yes, where?
*
No cremation required
Help me organise Evermore to look after our VIP from Dr Ann
Help me organise Passing Paws
Help me organise Ripple Aquamation to look after our VIP from Dr Ann
Help me organise Lawnswood to look after our VIP from Dr Ann
I will ring Lawnswood & organise them coming to our home directly
Cremation, no return of ashes required
Please let us know if you have special requests for aftercare
*
I understand the appointment may be discreetly audio recorded for accurate clinical notes.
I understand
I would prefer this form be used to refer me to another vet as I prefer no recording
Please confirm you are the authorised person to make this appointment for compassionate home euthanasia or you are the authorised person's representative (Y) yes
*
Please contact Ann to say you've done this - Sending her a text to: 0434 380 400
Form Completed by
*
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