Appointment form for In-Home Euthanasia

Appointment form for In-Home Euthanasia

Thank you for taking the time to complete this form. We understand this is a difficult time and our team is honored to support you and your pet with care and compassion.The information you provide will help our veterinarian prepare for the visit and ensure the experience is as peaceful and respectful as possible. Please complete the form as thoroughly as you are able. Once submitted, our team will review your responses and follow up with any next steps needed to confirm your appointment.
Date

MonthDayYear
Date
Full Name

First NameLast Name
Contact number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Name

First NameLast Name
Secondary Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet's name
Species
Breed
Sex
Color
Age or birthdate
Current weight in pounds

Please briefly describe the reason you are seeking euthanasia at this time (e.g., quality of life concerns, chronic illness, pain, mobility changes):
Current veterinary hospital(s) and/or veterinarian(s)
Does your pet have any fearful or aggressive behavior towards strangers?
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.

I wish to have one complimentary paw print impression for a keepsake.
Please let the staff know if would like additional paw prints. Up to 3 additional paw prints can be purchased for $8 each.
I wish to have a complimentary lock of hair for a keepsake.
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?
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.
Aftercare options:
Private cremation - ashes are returned in an urn to the hospital for pickup; Communal cremation - no ashes are returned
- By selecting home burial/owner-arranged aftercare, I acknowledge and understand the following:
  
  • I am fully responsible for my pet’s aftercare and final disposition.
  • I am responsible for complying with all applicable local and state regulations regarding burial or disposition of remains.
  • I understand euthanasia medications may pose risks to wildlife, scavengers, other animals, and the environment if remains are not handled properly.
  • I agree to prevent access to my pet’s remains by wildlife, pets, or other animals.
  • I understand burial should not occur near wells, streams, ponds, wetlands, or other water sources.
  • I understand caution should be used when digging to avoid underground utilities or infrastructure.
  • I acknowledge that natural postmortem changes may occur after passing, including release of bodily fluids, movement, or sounds.
  
  By choosing owner-arranged aftercare/home burial, I assume full responsibility and release and hold harmless Greater Annapolis Veterinary Hospital, its veterinarians, and staff from any liability related to the handling, burial, transportation, or disposition of my pet’s remains.
- Acknowledgment
- Signature
- Date
  
  MonthDayYear
  Date
- 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.
- 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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Appointment form for In-Home Euthanasia

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.