Bri-Ezy Veterinary Relief and Mobile Services, LLC Euthanasia Appointment Request and Signed Consent Form

Bri-Ezy Veterinary Relief and Mobile Services, LLC

Euthanasia Appointment Request and Signed Consent Form to be completed before scheduling confirmation of services
Client's Full Legal Name*

First NameLast Name
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Current Veterinarian: Clinic Name, Phone, Address
Pet's Name*
Breed*
Color*
Sex - Male, Female, Spayed, Neutered*
Weight (in lbs or kg)*
Current Medical Concerns - List major concerns relevant to the euthanasia request
Current Medications: If your pet is on any pain medications or anti-anxiety medications, I generally DO recommend that you still give these medications on the day of euthanasia if possible. The goal of euthanasia is comfort, if we remove these medications abruptly, they will have a period of discomfort prior to my visit, and these medications can continue to help them maintain comfort and aid in the euthanasia process. If you have questions, feel free to reach out. If your pet is not on any medications, mark NA, otherwise list known medications
Behavior Concerns to be aware of/History of aggression with new people/bite history - If "no," write NA; If "yes," please describe
To the best of my knowledge and belief, this pet has not bitten anyone during the 15 days preceding the requested date of euthanasia.

YesNo
Please read and initial each statement below to indicate your understanding and consent:

Your initials are required for each statement.
I am the legal owner or authorized agent for the pet described above and authorize euthanasia.*
If your pet is greater than 50 pounds, you or someone else of your household/acquaintance will be available at the time of euthanasia to help load them into a vehicle *
I understand that euthanasia is irreversible and involves the humane ending of my pet's life.*
I have had the procedure explained to me and all my questions have been answered.*
I understand that once performed, euthanasia cannot be reversed.*
Home Euthanasia and/or Home Visit Quality of Life Consultation (please select one):

I am requesting a home Euthanasia ONLY appointment (no quality of life consultation/medical exam) at a cost of $350 - this does NOT include after care - see below for additional optionsI am requesting a quality of life consultation/medical exam ($293/hr) that may result in a continued palliative care discussion OR euthanasia: If euthanasia is elected during the quality of life consultation, the total cost is the combined cost of the consultation with the euthanasia ($443) - this does NOT include aftercare, see below for additional optionsMy pet has already passed at home, I am requesting help with aftercare ONLY - $150 for cremation pick up within our service area, this does NOT include after care cost, see below for additional options
After Care Options and Pricing - the pricing below is for after care/cremation ONLY, this does not include cost of euthanasia, quality of life consult, or cremation pick up visits as listed above (please select one) - Ashes are typically returned in 1 to 2 weeks:*

I request communal cremation ($103) - ashes will not be returned, but my pet's ashes will be spread in a pet cemetery on the grounds of the crematorium).I request individual cremation (Individual/Separate ($213) - My pet will be cremated at the same time as other cremation companions, but will be placed in separate partitions within the cremator, and the individual ashes will be returned to me in a private urn (Acacia urn at no additional charge).I request private cremation (Private Cremation ($357) - My pet will be cremated alone without any cremation companions and the ashes will be returned to me in a private urn (Acacia urn at no additional charge).I have chosen to keep my pet at home to bury on private property. As such I acknowledge that I am aware of, and will comply with any and all local ordinances regarding laws restricting the practice of home burial, in addition to compliance with the appropriate location and depth of burial. I hold harmless and release Bri-Ezy Veterinary Relief and Mobile Services, LLC from any liability related to my choice and action to keep my pet at home for burial.
If choosing "yes" to home burial above: Please confirm the following; I am aware that if ingested by another animal, the chemical form of euthanasia medication presents a lethal risk to local wildlife and it is my responsibility to make sure the hole is at least 6 feet in depth to prevent access to my pet’s remains.

YesN/A - I am NOT choosing Home Burial
Optional Services

These services are in addition to those listed above, the added cost is listed below
I am requesting services outside of regular business hours, Monday through Friday 8am to 6pm. Note: Holidays are considered after hours. ($250)

YesNo
Additional Body Care Options (please select one):*

Ink Paw Print ($20)Clay Paw Print ($30)Custom Urn ($60) - Includes an Ink paw print of my pet and my pet’s name on the Urn (Note: Custom Urn takes between 2 to 4 weeks for return of pet's ashes)Fur Clipping (no charge)
Additional Questions/Concerns/Requests - to be reviewed upon reciept
Owner's Electronic Signature*

Clear
Please provide your legally binding signature here.
Owner's Full Legal Name*

First NameLast Name
If you choose to take your pet home for burial, please be aware that you must bury your pet at least 6 feet deep and confirm the legality of the burial location with your local municipality.
Should be Empty:

Bri-Ezy Veterinary Relief and Mobile Services, LLC

Please read and initial each statement below to indicate your understanding and consent:

Optional Services