Peaceful Partings Website Client Consent Form

Peaceful Partings Client Consent Form

To request an appointment or availability, please complete the online consent form below.
Today's Date

MonthDayYear
Date
Client Information
Full Name

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

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Regular Vet Clinic

Pet's Information
Pet Name
Species
Breed
Color
Gender
Altered?
Age (in years)
Weight (lbs)

How would you prefer your pet's body is cared for?
Individual Partitioned Cremation / Ashes Returned

The provider will issue a certificate of cremation.
Ashes Container (Included With Cremation)
How would you like your pet’s name displayed on cremation certificate?
How would you like you or your family’s name displayed on cremation certificate?
Clay Pawprint (1st included; additional + $30 each)
1 pawprint is included in the service, at no charge. Each additional pawprint is $30.
Ink Print (+ $20)
Fur Clipping (+ $7)
Nameplate (+ $17)

Payment Disclaimer
I owner/agent of said pet above do understand the fees associated with euthanasia services and cremations services that I have requested for my pet. I owner/agent do understand and authorize staff or agent of Peaceful Partings to charge the $50.00 deposit which is required to reserve my stated appointment with Peaceful Partings, and I do understand that said $50.00 fee is nonrefundable if I decide to change or cancel the appointment for any reason. In the event of a cancelation within 2 hours of my appointment, the cancelation fee is $150.00.

I understand that an additional $45.00 Doctor Travel Fee will be processed if my pet passes naturally and I am unable to notify Peaceful Partings prior to my scheduled appointment.
Payment Disclaimer Initials
Payment Disclaimer Initials
Consent

If you would like to schedule an in home euthanasia service, please call us so we may obtain all your information and your pet information. There is a $50.00 deposit required to set appointments. This fee is non-refundable and is charged if there is a change or cancellation for any reason. If a cancellation within 2hrs of my appointment, the cancellation fee is $150. I certify that I am the [ legal owner / duly authorized agent for the owner] of the animal described above and do hereby give assigned veterinarian and technician/assistant of Peaceful Partings and any authorized agents, staff, or representatives full and complete authority to euthanize and dispose via cremation services the ashes of said animal in a humane manner. If cremation is agreed upon, disposition of the body of said animal is left to the judgment of the veterinarian. I hereby forever release assigned veterinarian and technician/assistant of Peaceful Partings and any authorized agents, staff, or representatives from any and all liability for euthanasia and disposal of said animal. Cautions should be taken by owner when disposing of animals euthanized with drugs/chemicals. To the best of my knowledge, the said pet described above has not bitten, scratched, or otherwise potentially exposed any person or other animal to rabies in the past ten (10) days. Other Species: To the best of my knowledge, the animal described above has not bitten, scratched, or otherwise potentially exposed any person or other animal to rabies in the past thirty (30) days. I understand that if the animal described above has bitten or otherwise potentially exposed any person within the time specified, a rabies test must be performed.
Consent Initials
Consent Initials
Veterinary Exam Requirement

To comply with state veterinary regulations, we require proof of a physical exam completed within the past 12 months. If an exam has not been performed or I have not provided documentation, I understand a Euthanasia Exam resulting in a fee of $35 will be performed in order to provide euthanasia services that I am requesting.
Upload proof of an exam within the past 12 months.

Cancelof
Veterinary Exam Initials
Consent Initials
Mortality Insurance

If the animal described above is insured under a mortality insurance policy or any other type of insurance policy, the owner/agent hereby agrees that it is his/her responsibility, and not the veterinarian's, to notify the insurance company as required by the terms of any applicable insurance policy. I have read and understand this authorization. To the best of my knowledge, the information I have provided is true. I understand that my wishes may be carried out immediately upon my signing this agreement. Fees for these services have been explained to me.
Mortality Insurance Initials
Mortality Insurance Initials
Return of Ashes

By initialing this section, you acknowledge that there may be the occasional delay in the return of ashes following cremation. Peaceful Partings operates with a small team and travels extensively at all hours to provide compassionate care for pets. We value your pet and it is our goal to reunite you as soon as possible. Thank you for your patience and understanding.
Return of Ashes Initials
Return of Ashes Initials
Parking Notice

Please note we need parking up in front of the home as close to the main entrance or where we will be visiting with your pet. Any damage or personal harm to staff or vehicle due to hazardous or inaccessibility to the home will be the responsibility of the homeowner. A fee may be applied if parking and walkway conditions are hazardous or unsafe.
Parking Notice Initials
Parking Notice Initials
How did you hear about us?
Signature
Date and Time of Signature

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Peaceful Partings Client Consent Form