Euthanasia & Payment Consent Form
Owner/Agent Name
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First Name
Last Name
I understand that the owner name and signature must match the name on the account being used for payment.
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Yes
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Format: (000) 000-0000.
Email
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example@example.com
Pet's Name
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Species
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Please Select
Dog
Cat
Pocket Pet
Bird
Goat/Sheep
Llama/Cow
Horse/Donkey
Breed
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Color
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Age in years
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Weight in lbs
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Sex
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Male
Female
Spayed/Neutered/Gelded
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Yes
No
How did you find us? (check all that apply)
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Crematory
Google
Bing
Veterinarian referral
Angel Vet
Social Media (Facebook, Instagram, Next Door, etc)
Friend
Other
After Care Arrangements & Acknowledgments
I understand that payment is a non-refundable booking fee.
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Yes I have carefully read and fully understand the foregoing provision.
I understand that all sales are final.
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Yes I have carefully read and fully understand the foregoing provision.
I understand that if I choose to reschedule, another payment is required and is also non-refundable
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Yes I have carefully read and fully understand the foregoing provisions
I understand that rescheduling is based on availability, and that there is no guarantee that an opening will be available.
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Yes I have carefully read and fully understand the foregoing provisions.
Please choose your preference for aftercare.
I would like to handle and take full responsibility for all aftercare arrangements myself. I am aware of any applicable laws and regulations regarding the burial of my companion animal's body and understand caution should be taken when disposing of animals euthanized with drugs/chemicals.
I would like a private cremation with the ashes returned
I would like a communal cremation and do not need the ashes returned
I certify I am the legal owner or duly authorized agent for the owner of the animal described above and give Holistic Veterinary House Calls and any authorized agents, staff, or representatives full and complete authority to euthanize my animal in a humane manner. I forever release and hold harmless Holistic Veterinary House Calls and any authorized agents, staff, or representatives from any and all liability for euthanasia of my animal.
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Yes
Dogs, Cats and Ferrets: To the best of my knowledge, the dog, cat or ferret described above has not bitten, scratched and/or 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 and/or 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.
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No rabies exposure
Food animals: I understand that after any of these medications have been used to euthanize a food animal, I will not allow the food animal to enter the food supply for humans, pets and/or wildlife.
Yes I have carefully read and fully understand the foregoing provisions.
I understand that the in home euthanasia procedure is only performed inside the home. I understand that the procedure is NOT performed outside, not performed in a vehicle, not performed on a patio or in any other location other than inside the home.
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Yes I have carefully read and fully understand the foregoing provisions.
I understand that while there are exceptions (when possible), Holistic Veterinary House Calls does not provide urgent end of life services. I understand that if my pet's health is severely compromised and the need for end of life services is urgent, I am advised to take my pet into my primary veterinarian or urgent/emergency care facility. I also understand that appointment times are approximate.
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Yes I have carefully read and fully understand the foregoing provisions.
I understand that for safety reasons, if my pet is fearful of strangers, is feral or aggressive, I will have them secured in a carrier and/or muzzled before Holistic Veterinary House Calls arrives at the home. I also understand that if administering the anesthesia becomes dangerous due to feral or aggressive behavior, then Holistic Veterinary House Calls will not perform the euthanasia procedure, will recommend calling animal control/services and payment remains non-refundable.
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Yes I have carefully read and fully understand the foregoing provisions.
I understand that for canine aggression cases the pet must be muzzled upon arrival. I understand that is it my responsibility to have my pet muzzled before the veterinarian arrives. I understand if muzzling becomes not possible, the appointment can be cancelled and payment remains non-refundable.
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Yes I have carefully read and fully understand the foregoing provisions.
I understand that anesthesia is administered via an intramuscular injection and that sometimes this can cause some temporary discomfort to my pet. I understand that for safety reasons it may be necessary to restrain my pet to administer the anesthesia which may cause my pet to cry, yelp or express discomfort. I also understand that once the anesthesia has been administered this means the process of euthanasia has begun. I understand that if I change my mind after the anesthesia has been administered I will need to immediately transport my pet to an urgent/emergency care facility to attempt a reversal. I understand that once the anesthesia has been administered the euthanasia process has begun and it may not be possible to reverse the process of euthanasia even with emergency medical intervention.
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Yes I have carefully read and fully understand the forgoing provisions
I understand that certain procedures/techniques may be necessary based on (but not limited to) my pet’s health status, existing medical conditions, age related changes, fragile vessels, body composition, etc. I understand that administering the euthanasia medication may require using more than one vessel, organs and/or other body locations. I also understand that, while they are rare, there can be involuntary responses during the procedure which include but are not limited to: muscle spasms, seizures, agonal breaths, etc.
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Yes I have carefully read and fully understand the foregoing provisions.
I understand euthanasia is the act of ending the life of an animal to prevent unnecessary suffering. To the best of my knowledge, the information I have provided is accurate and complete. I understand my wishes may be carried out immediately upon my signing this agreement. The non-refundable booking fee has been explained to me and I assume full responsibility.
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Yes I have carefully read and fully understand the foregoing provisions.
Signature
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Date
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Month
-
Day
Year
Date
Submit
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