Veterinary Euthanasia & End-of-Life Care Request
Submit your request and provide informed consent for veterinary end-of-life services. Please complete all required sections.
CLIENT (OWNER) INFORMATION
Please provide your contact details as the primary owner.
Full Legal Name (Primary Owner)
*
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Visit Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Secondary Contact Name
Secondary Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Are you the legal owner or authorized decision-maker for this pet?
Yes
No
Are all co-owners aware of and consenting to this request?
Yes
No
PET INFORMATION
Tell us about your pet.
Pet Name
*
Species
Please Select
Dog
Cat
Other
Breed
Age
Sex
Male
Female
Spayed / Neutered
Yes
No
Approximate Weight (kg or lb)
Microchipped
Yes
No
Unsure
VETERINARY HISTORY
Provide your pet's veterinary background.
Primary Veterinary Clinic Name
Clinic Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Last Veterinary Visit Date
-
Month
-
Day
Year
Date
Primary Diagnosis / Reason for Request
Has euthanasia been discussed with your regular veterinarian?
Yes
No
CURRENT MEDICAL STATUS
Describe your pet's current medical conditions and status.
Current Medical Conditions (Select all that apply)
Rows
Present?
Cancer
Kidney disease
Heart disease
Neurologic disease
Severe arthritis
Respiratory distress
Organ failure
Trauma
Other
If 'Other', please specify
Is your pet eating?
Yes
Reduced
No
Is your pet drinking?
Yes
Reduced
No
Mobility status
Normal
Difficulty
Non-ambulatory
Signs of pain or distress?
Yes
No
Unsure
Seizures in last 48 hours?
Yes
No
Any history of aggression or fear-biting?
Yes
No
If yes, please provide details
MEDICATIONS
List all current medications and allergies.
Current medications (name & dose if known)
Time of last medication dose
Known drug allergies
Yes
No
If yes, please specify drug allergies
QUALITY OF LIFE (CVO-DEFENSIBLE)
Please rate the following aspects of your pet's quality of life.
Pain appears controlled
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
Appetite
Very poor
1
2
3
4
Excellent
5
1 is Very poor, 5 is Excellent
Mobility
Not mobile
1
2
3
4
Normal
5
1 is Not mobile, 5 is Normal
Interest in surroundings
No interest
1
2
3
4
Very interested
5
1 is No interest, 5 is Very interested
Ability to rest comfortably
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
In your opinion, is your pet suffering?
Yes
No
Unsure
SERVICE REQUEST
Select the service you are requesting and your preferred appointment details.
Service Requested
In-home euthanasia
Hospice / palliative consult
Quality-of-life assessment only
Is this an urgent or crisis situation?
Yes
No
HOME & SAFETY DETAILS
Tell us about your home environment to help us prepare for the visit.
Residence type
Please Select
House
Apartment/Condo
Townhouse
Other
Floor level
Elevator available
Yes
No
Parking availability
Yes
No
Other pets present
Yes
No
If yes, please provide details about other pets
Children present during visit
Yes
No
AFTERCARE & REMAINS
Select your preferences for aftercare and keepsakes.
Aftercare Preference
Private cremation (ashes returned)
Communal cremation
Home burial (where legally permitted)
Transfer to family veterinarian
Keepsakes Requested
Paw print
Fur clipping
Ink print
ONTARIO-APPROPRIATE INFORMED CONSENT
Please read the consent statement below and provide your agreement and signature.
INFORMED CONSENT FOR EUTHANASIA / END-OF-LIFE CARE (ONTARIO) I confirm that I am the legal owner or authorized agent for the above-named animal and have the authority to make medical decisions on their behalf. I understand that euthanasia is the humane administration of medications intended to painlessly and permanently end my pet’s life. I acknowledge that the attending veterinarian has explained: * The nature and purpose of euthanasia * The medications used * The expected process and outcome * Reasonable alternatives, including palliative or hospice care (where applicable) I understand that once euthanasia has been performed, death is irreversible. I acknowledge that while euthanasia is intended to be peaceful, rare and unforeseen reactions or complications may occur. I consent to humane euthanasia being performed by a veterinarian licensed to practise in Ontario. I understand that emotional responses by family members or other pets may occur and accept responsibility for maintaining a safe environment during the visit. I have selected and understand my aftercare and remains preferences. I understand the professional fees associated with this service and agree to payment as outlined. I release the attending veterinarian and clinic from liability except in cases of gross negligence or willful misconduct, in accordance with Ontario law. I give my informed consent freely and without coercion.
I have read and understand the above information
I have read and understand the above information
I give informed consent for the requested service
I give informed consent for the requested service
Owner Digital Signature
Date of Consent
-
Month
-
Day
Year
Date
ADMIN (OPTIONAL)
For administrative use or additional preferences.
Preferred payment method
E-transfer
Cash
Cheque
Other
Consent to receive records & invoice by email
Yes
No
Submit Request
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