Forever Loved Veterinary Services booking request

Euthanasia and disposition consent
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*

Confirmation Emailexample@example.com
Pet's Information
What is your pet's name?*
What species is your pet?*

DogCat
When is your pet's birthdate?*
What is your pet's breed?*
What color(s) is your pet?*
What gender is your pet?*

MaleFemale
What is your pet's approximate weight?*
Is your pet nervous or aggressive with strangers? If yes, please briefly describe below.*
Why are you seeking euthanasia for your pet?*
Please choose one of the aftercare options below: *
Would you like an additional paw print or lock of hair? Please note, a lock of hair is provided at time of all euthanasia appointments (if requested), and all Individual or Private cremations include one terra cotta paw print from crematorium.*

Yes, I would like an additional paw print ($45)Yes, I would like an additional lock of hair (no charge)No
Do you have any additional concerns you would like addressed by the Veterinarian? If yes, please describe briefly below.
We would like to update your regular veterinarian(s). Where can we send updates about our services? If no regular veterinarian, please mark n/a for this. *
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 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.

On this date, I hereby give Dr. Christina Barber 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*

MonthDayYear
Date
Signature*

Clear
Physical Exam
Date: 
Temp:
Pulse: 
Resp:
BCS: 4/9
mm: light pink and slightly tacky
Eyes: 
Ears: not examined
Oral cavity: periodontal disease
Heart:
Lungs: normal
Abdomen: tense and unable to perform deep palpation
Musculoskeletal: difficulty ambulating with general stiff gait, general muscle atrophy
Integumentary: several skin 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):
Butorphanol (10 mg/ml):
Ketamine (100 mg/ml): 
Midazolam (5 mg/ml):
Telazol (100 mg/ml):
Xylazine (100 mg/ml):
Dexmedetomidine (0.5mg/ml):
Other: 

Hair clipped over

Pentobarbital Sodium (390 mg/ml) administered 
IV ga butterfly catheter
Intrahepatic
Intracardiac
Intrarenal



Cardiac and respiratory arrest confirmed via auscultation and visualization.
staff access code
Should be Empty:

Euthanasia and disposition consent

Pet's Information