Euthanasia Appointment Request Form

Euthanasia Appointment Request Form

Peaceful and compassionate transition for your pet right in the comfort of your own home
Please ensure you're within our service areas (https://www.gentlewhiskers.com/service-areas) and please review our pricing and in-home euthanasia information (https://www.gentlewhiskers.com/in-home-euthanasia) prior to filling out this form.
Primary Owner Full Name

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

Other
Pet Breed (Predominant)
Pet Estimated Weight in lbs
Pet Spay/Neuter Status
Pet Color(s)
How far out are you looking to schedule the euthanasia appointment? Please provide a few preferred dates/times.
Do you have a separate quiet room or area in your home for the in-home euthanasia visit to take place?

Other
We only offer aquamation/water cremation for our aftercare services via our exclusive partner, Resting Waters/Evvi Aftercare. 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.

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 in detail your pet's 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 using it. We do not accept cash, check, CareCredit, Scratchpay, etc.
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.
We only offer aquamation/water cremation for our aftercare services. We do not offer traditional flame cremation.
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.
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).
After hours and/or weekend availability for euthanasia appointments only at our full discretion. Additional fees will apply.
All house call and in-home euthanasia appointments include a 60 min estimated time of arrival window.
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.
Please verify that you are human
Should be Empty:

Euthanasia Appointment Request Form

Terms & Conditions