Euthanasia Appointment Request Form

Euthanasia Appointment Request Form

Peaceful and compassionate transition for your pet right in the comfort of your own home
Primary Owner Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Occupation/Profession
Secondary Owner Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Occupation/Profession
Relationship to Primary Owner
Address (Location of House Call Visit)*

Street Address

Street Address Line 2

CityState

Zip Code
Pet Name*
Pet Estimated Date of Birth*

MonthDayYear
Date
Pet Species*

FelineCanine (<25 lbs only)RabbitFerretRatOther
Pet Breed (Predominant)*
Pet Estimated Weight in lbs*
Pet Spay/Neuter Status*

Male IntactMale NeuteredFemale IntactFemale SpayedUnknown
Pet Color(s)*
Do you have a separate quiet room or area in your home for the in-home euthanasia visit to take place?*

YesNoOther
We only offer aquamation/water cremation for our aftercare services via our exclusive partner, Resting Waters. More info available on our website or at www.restingwaters.com. This is a more environmentally-friendly option as compared to traditional flame cremation, which we do not offer. Please select one of the following aftercare options.*

Individual Aquamation with Remains Returned (one ink paw print, one fur clipping, and one clay paw impression included; ashes returned in a complimentary paper-based scattering vessel - wooden box and other urn options available as add-on)Individual Aquamation with Scattering Service (NO remains returned; remembrance item package not included but available as add-on)I would like to bury my pet on my compound (no aquamation services needed, no remembrance item options available). I understand and agree that I will need to bury the remains at least 3-5 ft deep to prevent scavengers from being exposed to and getting sick from euthanasia medications.Undecided. I would like to discuss with Dr. Boey about the above options.Other
Does your pet have a history of aggression or anxiety? Any known history of scratching or biting? Please describe in detail. This is important to determine if anti-anxiety medication/sedatives would be needed prior to the appointment.*
Please describe your pet's brief medical history and the reason(s) for electing humane euthanasia.*
If you have any previous medical records regarding your pet's current medical condition influencing your decision for euthanasia, please attach them here.

Cancelof
Please select your preferred payment method. Our preferred payment method is Zelle, and you may be offered a small discount for selecting it. We do not accept cash, check, CareCredit, Scratchpay, etc.*

Zelle (preferred)VenmoPayPalCredit/debit card (Visa, Mastercard, American Express, Discover, Apple Pay)Other
How did you hear about us?*
Please describe directions to park near your home.*
Please describe directions to access to your housing unit. If you live in a gated community, please provide callbox instructions or any access codes.*
Terms & Conditions
Submission of this form is considered a request. Someone will reach out via the email address provided within 1-2 business days to start the appointment confirmation process. Based on the information provided, we reserve the right to refuse service to anyone for any reason.*

I understand and agree
We only offer aquamation/water cremation for our aftercare services. We do not offer traditional flame cremation.*

I understand and agree
A full deposit of the travel and euthanasia fees are required prior to confirmation of the appointment. Aquamation fees will only be collected during the appointment. All charges for services rendered are due and payable in full at the time of service.*

I understand and agree
The travel fee is refundable up until 24 hours prior to your appointment time, while the euthanasia fee is always refundable. However, if a quality of life consultation has already been provided and/or if euthanasia medications have already been drawn up during the appointment but you choose not to proceed with the euthanasia, a $100 cancellation fee applies (i.e., refund of full deposit minus travel fee minus $100).*

I understand and agree
After hours and/or weekend availability for euthanasia appointments only at our full discretion. Additional fees will apply.*

I understand and agree
All house call and in-home euthanasia appointments include a 60 min estimated time of arrival window.*

I understand and agree
We have a zero tolerance policy for abusive behavior by clients. In the event a client engages in any such behaviors, we will discontinue services immediately.*

I understand and agree
Please verify that you are human*
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Euthanasia Appointment Request Form

Terms & Conditions