Home Euthanasia Request Form
Client Details:
Full Name
*
Title
First Name
Last Name
What would you like us to call you?
*
(For example, "Sarah" or "Mr. Jones")
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Phone Number
*
-
+44
Phone Number
E-mail
*
example@example.com
Are there any parking restrictions or instructions?
*
Is anyone in your household immunocompromised?
*
Who is your current vet?
Would you like us to inform your vets of your pet's passing?
Yes
No
Pet Details
Name:
*
Species
*
Please Select
Dog
Cat
Rabbit
Small mammal
Bird
Exotic
Breed:
*
Sex:
*
Colour:
*
Date of birth:
*
-
Day
-
Month
Year
Date
Weight:
*
Colour:
*
Microchip Number (if known):
Appointment Preferences
Preferred Appointment Date:
*
-
Day
-
Month
Year
Date
Preferred Appointment Time
*
Hour Minutes
AM
PM
AM/PM Option
Please indicate the pace that feels most comfortable for you during your our visit.
*
I need support or advice in making the decision - I'm not sure if I am ready.
I have made my decision, but I would like to go slowly - I might need extra time during the process.
I don't want things to be rushed, but I do not need extra time at any stage of the process.
How would you like us to interact with your pet during the process?
*
I would like the vet to try to bond with my pet as much as possible.
I don't mind if the vet engages with my pet, as long as it's not excessive.
I would prefer the vet did not try to bond with my pet.
How would you like us to interact with you during the process?
*
I would prefer not to be present during the process.
I would like to be present, but I only want the vet to communicate the essential details of the process.
I am happy to chat with the vet and would like to keep things light.
Do you have children or other pets that will be present during the process? If yes, please let us know how you would like them to be involved.
Have you thought about aftercare arrangements?
*
I haven't thought about it yet/unsure.
I would like to keep my pet for a home burial.
I would like my pet to be cremated and I DO want their ashes returned.
I would like my pet to be cremated and I DO NOT want their ashes returned.
If you would like your pet to be cremated, can we pass your contact details to our crematorium? They will then contact you to discuss all of your options.
Please Select
Yes
No
If you would like your pet to be cremated, do you have a favourite blanket, toy, or special item that you would like them to travel with?
Do you have any other special requests or important information that you would like us to know?
Would you like a hair clipping, paw print, or nose print? (No additional cost) Please tick all that apply.
Hair clipping
Paw print
Nose print
None of the above
May we send you a condolence card?
*
Please Select
Yes, please.
No, thank you.
Consent
Please read and confirm all of the following statement.
*
I confirm that I am the pet's legal owner and have the right to make medical decisions regarding euthanasia.
I understand that euthanasia is irreversible. The procedure has been explained and I have had the opportunity to ask any questions about the process.
I confirm I am making this decision voluntarily and without coercion.
I understand that by submitting this form, I give Kelly Vets full and complete authority to euthanise my animal in a humane manner. Furthermore, I forever release the doctor or her representatives from any and all liability from this euthanasia.
Submit
Should be Empty: