Ark Angel Vet Appointment Form
A Perth Metro Based, dedicated At-Home Euthanasia Practice with Dr Patrick
Thank you for trusting Dr. Patrick with this important farewell. This form takes about 5 minutes to complete and helps me prepare a gentle, personalised experience for you, your family, and your beloved pet. A fee summary will be sent to you before any commitment is made.
What Other Families Have Experienced
"Dr Patrick was amazing, he treated my little dog with the utmost care and respect, it was exactly the send off I wanted for her and she deserved. I recommend the hour visit, he explained everything and we had lots of time to spend with her, well worth every dollar, you won’t be disappointed". Tracey S.
Your Details
Name
Prefix
First Name
Last Name
My phone number
*
Email
*
My Address
*
Please include any details on the best place to park, etc.
Who will be attending the appointment (First Names)
*
Include children’s first names and ages. Include family members not attending so I can add them to my Condolence Card.
My Pet’s Details
My Pet’s Name
*
My Pet Is a:
*
Please Select
Dog
Cat
Rat
Mouse
Bird
Guinea Pig
Rabbit
My Pet's Gender
*
Please Select
Male Sterilised
Female Sterilised
Male Not Sterilised
Female Not Sterilised
My Pet’s Breed and Colour
*
My Pet’s Age
*
My Pet’s Body Weight
*
in kg
My Pet’s Microchip (MC)
*
Does not have a Microchipped
Has a MC but don't know the number
Not sure.
Has a Microchip
Pet's Microchip Number
Enter the microchip number here after selecting Microchip Number.
My Pet’s Behaviour
*
Very friendly.
May be anxious with strangers.
May be reactive or aggressive and a potential bite risk. May need pre-visit meds, or extra sedative doses, that will incur an extra fee.
Behavioural euthanasia for aggression - your pet will need pre-visit sedation and anti-anxiety medications that will incur an extra fee.
My Pet’s Regular Veterinary Practice
*
You can add any recent specialty centre or emergency hospital visits.
Veterinary Hospital’s Email.
I will notify them of your pet's passing so they can update their records. This helps prevent any future appointment reminders or communications that might arrive during your grieving period.
Pet’s Diagnosis
*
Age related illness
Cancer
Heart Disease
Kidney Disease
Arthritis
Loss of mobility
Paralysis
Dementia
Diabetes
Blindness
Hyperthyroidism
Hypothyroidism
Spinal Disease
Seizures
Cushings / Addisons Disease
Serious Dental Disease
Unknown diagnosis
Other - Please add to the following field box
My Pet’s Brief Medical History
Please share any past diagnoses, treatments, medications, surgeries, or other important medical details.
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Choose the Farewell That Feels Right for Your Family
The questions below will allow you to customise how your pets farewell takes place. This helps me prepare the setting that feels right for you, your family and your pet.. Fees are based on your choice of options, I will send you a fee summary as soon as possible.
What matters most to you during your pet’s farewell? Please select one or more options below ❤
*
The Perfect Family Goodbye, a calm, unhurried goodbye, A gentle, peaceful experience with plenty of time to say goodbye. I highly recommend this option for families where children of all ages are present.* Includes a Pre- Euthanasia exam and consultation. (Approximately 60 minutes)
Complimentary with The Perfect Family Goodbye Option. A unique and personalised memorial experience. A softly guided, meaningful farewell that may include flowers, floating candles, music, or personal keepsakes, creating a peaceful space to honour your pet’s life. I will gently support you in shaping something that feels right for you and your family. This allows children to be part of the memorial for their beloved pet. Available as am optional part of The Perfect Goodbye at no extra fee.
The Procedural Goodbye, practical farewell option for those who may prefer a shorter, appointment. This option offers calm, dignity, and gentle care, but with a briefer experience. (Approximately 30 minutes)
A Saturday appointment.
A Sunday appointment.
Public Holiday or out of hours
A Behavioural Euthanasia. (For aggressive or high anxiety pets).
Cremation Options
Cremation Fees are - Charge Directly to you by your chosen provider. Not included in my fees.
For more information, please visit
lawnswood.com.au
Cremation and aftercare options
*
Water-based cremation (Aquamation) - visit rippleaquamation.com.au
Traditional flame cremation (Lawnswood) - visit lawnswood.com.au
Cremation without ashes returned (includes transfer)
Home burial — no cremation needed
Pet Transfer Options
If needed after our appointment, I can transfer your pet to your chosen cremation facility.
*
1. Premium Direct: I will transfer your pet to the Facility after our appointment, if possible.
2. Standard Indirect: I will transfer your pet to my home overnight for collection the next day or Monday. (Tuesday if there is a Monday Public Holiday)
3. No Transfer Needed - We will be doing a Home Burial
Other
Payment Options
Pre-Payment is preferred and appreciated.
Your Payment Preference
*
PayID - (No Fees)
EFT - Electronic Funds Transfer (No Fees)
Credit Card over the phone or at the end of our visit. (Fees apply)
Debit Card at the end of your visit. A physical card is required (30 cents flat fee).
Please Select Your Preferred Appointment Day and Time
I will contact you re an appointment time as close as possible to your requested time
Appointment Availability
If you are not able to find your ideal time, please fill in your day and time in this box. Dr Patrick will contact you to confirm your appointment time.
Fees
Submitting this form is non-binding. I will calculate your fee based on your selections, then send you a fee summary for your approval. My fees are based on the first two parts below, the third is optional. 1. The type of appointment and day of you choice. 2. Travel to your home. 3. Transfer of your pet to a cremation facility if needed by me. (Optional)
Are You Claiming the Euthanasia Fees from Pet Insurance
*
No
Yes
Who connected us?
*
Google/Websearch
Social Media - Facebook
Family or Friend
My Regular Vet
Emergency Vet
Dr Ann Vet
Specialist
I am already a client
Other
Referring person's name
Please enter the name if you selected Family or Friend., so I can pass on my gratitude__.
Euthanasia Consent
*
I consent to the euthanasia of my pet to be performed by Dr Patrick Africano. I also understand that Dr Patrick may use audio recording during the visit to assist in completing the medical record. Please submit your consent by clicking the button below
Questions, Concerns, and Special Requests — Or if you need clarification regarding any of the options.
Please let me know if you have any particular requests or concerns.
Thank you for signing and submitting this form
*If this form is not submitting please check for a red notice in the form above for a required field to be completed. As soon as it arrives, I will personally review your form, prepare your total fee and confirm your appointment time for your approval. Dr Patrick: 0408915550
Would you like me to know anything special about your pet before I arrive?
Please send me a quick text to let me know you have completed the form. Dr Patrick
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