Forever Loved Veterinary Services booking request

Client consent and information for peaceful in-home euthanasia

Thank you for trusting Forever Loved Veterinary Services during this emotional time. This form helps ensure that your beloved pet remains comfortable throughout the process and that your family receives the support and peace you deserve. Please complete the information below to the best of your ability.
Your name*

First NameLast Name
Spouse or partner's name

First NameLast Name
Email for important appointment, follow-up, and/or payment links ONLY*

Confirmation Emailexample@example.com
Phone Number (capable of receiving text messages and secure links)*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
If applicable, please enter gate or entry codes
Gate Code
Pet's name*
What species is your pet?*

DogCatOther
What is your pet's birthday (estimate is ok)*
Month / Day / Year
What gender is your pet*

MaleMale neuteredFemaleFemale spayed
What is your pet's breed?*
What is your pet's weight?*
Number in pounds
Is your pet CURRENTLY taking any medication(s)? Please list all NAMES, STRENGTHS, and FREQUENCY given. If no medications, please mark n/a. *
What are your preferred days to schedule appointment?*
What is your preferred arrival window for the appointment?*

8am - 10am10am - 12pm12pm - 2pm2pm - 4pmafter 4pm
Why are you seeking euthanasia for your pet?*
Is your pet nervous/aggressive with strangers? If yes, please briefly describe *
Please choose one of the aftercare options*

NO CREMATION - I will handle my pet's remainsCOMMUNAL CREMATION - I understand that my pet will be cremated and I WILL NOT receive any ashes returnedINDIVIDUAL CREMATION - I understand that my pet will be cremated and I WILL BE receiving ashes returned. My pet will be cremated along with other pets but FULLY separated by partition and ONLY MY pet's ashes will be returnedPRIVATE CREMATION - I understand that my pet will be SEPARATELY cremated (the ONLY pet within the chamber) and I WILL BE receiving ashes returned
I understand that, I the undersigned, am responsible for reviewing and adhering to local regulations due to the risks, including but not all inclusive, ground contamination, risk of serious illness to any exposed animals and/or humans, including even death if any buried remains are disturbed or unearthed
Signature

Clear
Which urn style feels right?*

'Tree of life' carved wood urnCedar memorial urnDecorative blue metal urnDecorative tan metalBlue scatter urn with pawprintsSatin pouchNot sure yet*
If you’re unsure right now, that is ok. You can confirm your urn choice later. Images of the urn styles can be viewed on our website when it feels right.

*Please note: cremation and preparation of any selected memorial items will begin once an urn style has been chosen. The estimated timeline for return is based upon when all selections are finalized and shared with the aftercare facility.*

**Due to the sensitive nature of our care, please let us know if you would prefer to receive an email with the images of the included urn styles directly as it is NOT our standard of care to automatically send these images.**
Would you like a memorial terracotta pawprint? Please note that a pawprint is NOT included with communal cremation service.*

Yes, please ($45 plus shipping)No, thank you
How many pawprints would you like? *
Each terracotta pawprint is $45 plus shipping
Would you like an additional memorial terracotta pawprint? (please note that one print is included with the cremation service you selected)*

Yes, pleaseNo, thank you
How many additional pawprints would you like?*
Each additional pawprint is $45
Would you like the included lock of hair?(no additional charge for this keepsake)*

Yes, pleaseNo, thank you
How many memorial locks of hair would you like overall?*
Keepsake lock of hair collected at time of appointment
If my pet weighs more than 30 pounds, I understand that a family member is responsible for transferring my pet into the doctor’s vehicle for the selected aftercare services*

YesNo, and aware that scheduling coordination must occur prior to finalizing appointment date/timeNo aftercare services have been selected
How would you like to supply payment for appointment and aftercare services? *

Zelle transfer*Credit card (payment processing fee will be applied by our secure payment provider)
I understand that by selecting Zelle as my payment method, I confirm that I have an active Zelle account associated with the phone number or email address provided on this form, unless otherwise indicated (please provide the contact information able to complete a Zelle payment below in the other concerns section end of this form). I understand that I will receive a secure Zelle payment request from Pawprint Veterinary Services, LLC, and that payment is required at the time of scheduling to confirm my appointment. I understand that any additional services or aftercare selections (including cremation services and memorial items) must be paid for prior to/or at the time of the appointment. I acknowledge that Pawprint Veterinary Services, LLC is unable to assist with transporting my pet’s remains to the cremation facility unless payment for selected aftercare services has been received. I understand that Forever Loved Veterinary Services/Pawprint Veterinary Services, LLC does not carry cash and unable to provide change at the time of the appointment.*
How would you like to receive your pet’s remains or memorial items following aftercare services?*

Scheduled courier delivery to your home - $39*Shipped via secure USPS (tracking and signature release REQUIRED for completion of delivery) - $35Pick up from Lasting Paws Cremation Facility at your convenience (5644 N 53rd Ave, Glendale 85301 - no fee)No aftercare or memorial items have been selected
Once your pet's remains are returned and ready, the courier service will contact you directly to schedule delivery. Please don't hesitate to reach out if you have any questions - I am always here to help.

*Courier delivery beyond our standard service area may incur an additional fee and will be discussed when scheduling.
Do you have any additional concerns you would like addressed by the Veterinarian? If yes, please describe briefly
To help keep your pet’s medical record complete, a notification can be provided on your behalf, to your primary veterinarian of our services. Please provide clinic name for us to do so. If none, please mark N/A*
I understand that euthanasia is the act of humanely ending the life of an animal in a painless way to prevent any unnecessary suffering. I am completely satisfied that humane euthanasia is the appropriate course of action for the pet described above. I understand that once the procedure has begun, it cannot be reversed. I understand that the process may begin immediately following my signing of this document. Fees for these services have been explained to me, and I assume full responsibility for all charges applicable to such services.

I, the undersigned, do hereby certify that I am at least 18 years of age, and I am the legal and rightful owner (or duly authorized agent for the owner) of the pet described above.

I certify that, to the best of my knowledge, this pet has not bitten, scratched, or otherwise potentially exposed any person or other animal to rabies within the past ten (10) days. I understand that if the pet described above has bitten or otherwise potentially exposed any person within the time specified, a rabies test must be performed and I am responsible for the costs that may be incurred with testing.

I, the undersigned, do hereby certify that I have been advised that I am responsible for reviewing and adhering to local regulations due to the risks, including but not all inclusive; ground contamination, serious illness to any exposed animals and/or humans, and even including death can occur if any buried remains are disturbed or unearthed.

By signing below, I agree all conduct and communication with Forever Loved Veterinary Services, Pawprint Veterinary Services, LLC, Christina Barber, DVM, Christina Reale, and any staff or representatives in a respectful and non-harassing manner. I understand that slander, libel, harassment, threats, or defamatory statements made against the above entities or individuals will result in legal action as permitted under state and/or federal law. I acknowledge that this policy is in place to protect the safety, reputation, and wellbeing of all parties involved.

On this date, I hereby give Dr. Christina Barber (aka Christina Reale) or any agent of Forever Loved Veterinary Services, Pawprints Veterinary Services, LLC, complete authority to perform humane euthanasia of my pet, provide final disposition of the remains as elected above, and I release and hold harmless all agents, staff, and representatives of Pawprints Veterinary Services, LLC from any and all liabilities arising from the euthanasia and disposition of the remains. I have carefully read and fully understand the foregoing provisions.
Date paperwork completed*

MonthDayYear
Date
Signature*

Clear
Physical Exam
Date: 
Temp (degrees F):
Pulse (beats/min): Resp (breaths/min):
BCS: 4/9
mm: light pink and slightly tacky
Eyes: OU
Ears: not examined
Oral cavity: periodontal disease
Heart: normal rhythm, no murmur ausculted
Lungs: normal BV sounds
Abdomen: tense and unable to perform deep palpation
Musculoskeletal: difficulty ambulating with general stiff gait, general muscle atrophy
Integumentary: several raised masses 
Neurologic: normal mentation / full exam not performed
Lymph nodes: normal
Genitourinary: NE

Assessment: poor QOL, appropriate to pursue humane euthanasia
Medication and euthanasia
Acepromazine (10 mg/ml): ml IM
Butorphanol (10 mg/ml): ml IM
Ketamine (100 mg/ml): ml IM
Midazolam (5 mg/ml): ml IM
Xylazine (100mg/ml): ml IM
Telazol (100 mg/ml): ml IM
Dexmedetomidine (0.5mg/ml): ml IM
Pentobarbital Sodium (390 mg/ml) administered
ml IV
Intrahepatic
Intracardiac
Intrarenal
Cardiac and respiratory arrest confirmed via auscultation and visualization.
staff access code
Should be Empty:

Client consent and information for peaceful in-home euthanasia