Appointment form for In-Home Euthanasia
We understand this is a difficult time for your family, we appreciate all the information you can provide as it will be sent to Dr. Phillips directly as well as the hospital.
Date
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-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Contact number
*
Please enter a valid phone number.
Secondary Name
First Name
Last Name
Secondary Contact Number
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet's name
*
Species
*
Please Select
Dog
Cat
Small mammal
Breed
*
Sex
*
Please Select
Male
Male, neutered
Female
Female, spayed
Unknown
Color
*
Age or birthdate
*
Current weight in pounds
*
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Briefly describe the reason for euthanasia:
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Current veterinary hospital(s) and/or veterinarian(s)
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Does your pet have any fearful or aggressive behavior towards strangers?
*
Please Select
Yes
No
If so, please briefly describe the behavior below:
If your pet is over 40 pounds, will there be someone in the home who can assist lifting the pet? If your pet is over 100 pounds, we will need to discuss pick up arrangements.
*
Please Select
Yes
No
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I wish to have one complimentary paw print impression for a keepsake.
*
Please Select
Yes
No
Undecided
Please let the staff know if would like additional paw prints. Up to 3 additional paw prints can be purchased for $6 each.
I wish to have a complimentary lock of hair for a keepsake.
*
Please Select
Yes
No
Undecided
Please let the staff know if their is a particular location of hair on the pet to keep.
Has your pet bitten any person on animal during the last 10 (ten) days, or been exposed to rabies?
*
Please Select
Yes
No
If your pet has been in the last 10 days, and is required by the State of Maryland to be tested for rabies, that test will be done at the owner's expense.
I, the undersigned, do hereby certify that I am the owner of the animal described above, or the duly authorized agent for the owner, that I am 18 years of age or older, and that I do hereby give Greater Annapolis Veterinary Hospital, their doctors, agents, servants and representatives full and complete authority to humanely euthanize said animal and I do hereby forever release Greater Annapolis Veterinary Hospital and its employees from any and all liability for so euthanizing said animal.
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Aftercare options
*
Please Select
Home burial
Private cremation ($230-$475 depending on weight)
Communal cremation ($72-$160 depending on weight)
Please call me, I have questions about my options.
Private cremation - ashes are returned to the hospital; Communal cremation - ashes will not be returned
I hereby certify that I am the owner or duly authorized agent for the owner of the animal described above, that I am 18 years of age or older, and that I hereby authorize the above method of disposition.
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I understand that payment is due prior to services being rendered. I understand that an invoice and online payment link will be sent to me upon scheduling the appointment and completing the required form.
*
Thank you for your trust in us to provide you with the comfort and dignity your pet and family deserve. It is our honor to serve you, and we send along our deepest condolences during this difficult time.
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