Euthanasia Consent

Thank you so much for filling out this information prior to your appointment, we greatly appreciate it. This will also provide information on the process, but please do not hesitate to get in touch with us if you have any questions at all before we see you. Take good care, Dr. Carrie

Name*

First NameLast Name

If we need to reach you, how would you prefer to be contacted?

Text (preferred on our end for communication)EmailPhone

Primary (Cell) Phone Number*

Area CodePhone Number

Address where services will be provided*

Street Address

Street Address Line 2

CityState

Zip Code

Please let us know here what your mailing address is, if different from the physical address listed above (disregard if the same address)

County *

Additional travel fee applies to residences outside of Dane County, we will send an invoice with exact pricing when we receive your form, thank you.

Email*

Additional Information for the Home Visit (description of your house/apartment)*

Please describe your house / COLOR / any additional features that will make your house easy to recognize. ** If you live in an apartment complex, please be as DETAILED as possible concerning how to recognize your building, where parking is in relation to your building, any distinguishing features of your building, and how / where to enter. If you know that Google Maps doesn't give accurate directions, let us know that as well.

Parking*

If we are taking your pet with us for cremation services, we prefer to park as close to the home as possible to make transportation easier. Please let us know where the best place to park would be, and if there is anything we should know about parking. If you have a driveway and can clear a spot close to an entrance that will really help us out. Thank you!

Pet's Name*

Species*

DogCatExotic (we can accommodate small mammals such as ferrets, rats, guinea pigs, rabbits, hamsters. Please let us know if you have another species in need of care)

My pet is*

FemaleMale

Age (can be approximate)*

Breed*

Color and/or Markings*

Weight*

Please note that we use the weight you provide to calculate dosage of medications, so it is important to be as accurate as possible. If you think your pet has gained or lost weight since the last known check, please let us know. Pricing is also weight-based. If the cremation service determines that the weight takes us into the next weight range, we will let you know the adjusted pricing. Thank you.

Medical conditions*

It is helpful for us to know what is happening with your pet, as we plan medications to use and prepare for the visit. if your pet is dealing with a major medical issue that might involve an organ system please let us know. For example, if there is heart failure, lung cancer, liver or kidney failure, or a history of seizures, this knowledge will allow us to prepare a gentle passage for your pet.

Additional information about your pet or the visit

Let us know if there is anything else that we should be aware of before the visit, for example if your pet is wary of new people, if they don't like to be approached or pet, things like that. Also, if there's anything special you would like at the visit, such as being outside (especially if it's a cold day so we're prepared) or if you'd like any certain arrangements made or done -- we are happy to accommodate. This visit is about you and your beloved pet, so let us know how we can make it as loving and comfortable as possible, and just how you would like it to be.

When I arrive at your home, I'll take time to meet you and your pet, discuss anything that you would like to and answer any questions that you have. Know that we can be wherever you would like to be -- inside or outside, wherever you and your pet would be the most comfortable. Pets can be in their beds, on the floor, on the couch, in the grass, we are completely flexible with where we are able to be. You may be able to hold your pet in your lap, as long as we are able to position in a way with no movement and sufficient access to administer medications.

The procedure first involves an injection of a sedative medication, which usually takes about 5-10 minutes to have the full effect -- this will allow your pet to fully relax, and take some deeper breaths, until they get very sleepy and to the point where they will be sedated and will not feel anything. Sometimes giving the sedative injection, which is just like getting a vaccine, will cause a reaction as any shot can do. Having some treats or just talking to and petting your companion can distract them while we give the first injection. I will typically step away after the first injection to prepare for the next, which usually also takes about 5-10 minutes. After that time, and when you are ready, I will give the next injection which will go into a vein. I will place a tourniquet, clip the fur around this area, and once I secure IV access and the injection begins, your pet will peacefully cross over the rainbow bridge. Sometimes this happens even before the injection is completely given.

I will typically use pets' hind leg areas for injections so that you are able to be with them up front near their head. You can continue to talk to your pet through the procedure, they will be able to hear you. I will check to make sure that your pet is not feeling anything -- though the injection that is given does not cause them any pain, I give the sedative so that securing vein access is allowable.

I will always discuss (as much as you would like) what I am doing and why during the time I am with you. If you don't need additional information or feel like talking that is absolutely ok too. Once I am able to start giving the medication through the vein, it does take effect relatively quickly, and will usually take about 2-5 minutes for the medication to be given. Afterwards, the I will listen to your pet's heart and let you know that he or she has peacefully passed.

This document will provide you with more detailed information about the visit and provide answers to frequently asked questions (not required reading)

After the procedure, we will help to coordinate aftercare for your pet if desired. There are the options of individual cremation with ashes returned, communal cremation with no ashes returned, or home burial. Please let us know what you would prefer. If cremation is chosen, the doctor will carefully transport your pet to the cremation service. Return with individual cremation typically takes about 2 weeks, and we offer shipping direct from Trusted Journey Cremation (included in price) or pickup from the cremation care facility in Poynette (price discounted $25)*

Individual Cremation -- your pet will be cremated individually, and you will receive ashes back in an urn of your choosing, options will be provided in the next sectionCommunal Cremation -- you will not receive ashes back with this service. Your pet's ashes will be scattered in a beautiful country location owned by the cremation service outside of Poynette, WI.Home Burial -- if you have a place for burial, or would otherwise like to take care of your pet afterwards. (Burials must be a minimum of 3 feet deep, with 2 feet of cover)

If you are choosing Individual Cremation with your pet's cremains returned to you, there are several urn options available, please make your selection below. All options are included in the service with no additional charge. Pictures of urn styles above. **Note -- cremains are accessible from ALL urns.

Hand Carved Urn (a brass nameplate may be added to this urn, write what you would like on it further down)Cedar Memorial Urn (a brass nameplate may be added to this urn, write what you would like on it further down)Decorative Metal Urn in BlueDecorative Metal Urn in TanScattering Tube (heavy cardboard), very easily accessible cremains

Personalized Clay Paw Print: The cremation service offers an impression of your pet's paw in either white or terra cotta clay as a memorial item. This option is unavailable with home burial, however, we can bring clay for you to make your own print at home. The paw print impression, made by experts at the cremation service is $55.*

Yes, I would like a WHITE clay paw print memorial returnedYes, I would like a TERRA COTTA clay paw print memorial returnedI would like a clay paw print kit to be left with me so I can make my own at home (for home burials only, $15 for kit)No, I do not request a clay paw print

Optional Paw Print Personalization: Midwest Cremation will have your pet's name in black ink on the front of the clay paw print. If you would like anything on the paw print that is NOT the name you have listed, please write it here (characters are limited to one word, a name or nickname). Also let us know below if you would NOT like your pet's name on the print.

Ink Prints: The cremation service also offers ink prints, either a nose print or a paw print. This option is unavailable with home burial, though there are kits available online to make your own ink prints at home. The ink prints are $35 each.

Yes, I would like an ink PAW printYes, I would like an ink NOSE printI would like BOTH an ink paw and ink nose printNo, I do not request an ink print

Personalized Engraved Nameplate: The cremation service offers a black name plate with gold lettering, that can be affixed to the Cedar Memorial Urn or the Rosewood Urn. If you would like this added, please let us know what you would like it to say (NOTE: limited to 14 characters each line, 2 lines total, all capital letters) Nameplate is $18 additional. If you would like more written than what will fit on one plate, we can add another, each is $19.

DOUBLE CHECK THAT YOU HAVE NO MORE THAN 14 CHARACTERS, INCLUDING SPACES, PER LINE.0/28

Other Memorial Products: Trusted Journey Cremation offers alternative urns as well as additional memorial products if you so choose, for an additional cost. If you would like a different urn or another memorial product, please review on their website and let us know what you are interested in receiving. https://mcsofwi.com/urnbook/

If your pet is over 30 lbs. and you are choosing cremation, would you be willing and able to help the doctor carry your companion to the vehicle after the procedure? We will have a soft stretcher with handles available, but may need assistance in lifting. No response necessary if this does not apply. If your pet is over 90 lbs, we will need 2 additional helpers.

Yes, someone will be available to helpNo, will not have anyone able to help (we can bring along an assistant, but this may affect availability and pricing)

If you are receiving ashes back, Trusted Journey Cremation Service in Poynette will send everything directly to you via USPS overnight shipping with signature delivery confirmation (included in pricing). They will reach out to you before sending so you know when to expect the package and to ensure that someone will be home. You can also choose to pick up directly from Trusted Journey. If you are receiving only memorial items, you can choose either direct shipping or pickup from the care facility in Poynette.

I will have cremains and/or memorial items shipped directly to me (Trusted Journey will reach out to you before sending. If receiving memorial items only, there will be a $25 shipping fee added, no extra charge for return of cremains +/- memorial items)I will pick up directly from Trusted Journey in Poynette (they will reach out to you once everything is ready, typically about 2 weeks — discount of $25 will be applied to your invoice, does not apply to memorial items only)Does not apply

For home burials only: we offer Euthabags, which provide a way to safely and gently protect your pet and the environment. These are not immediately biodegradable and are a way to secure your pet for burial. www.euthabag.com

Euthabag Small (3-20 lbs) $14Euthabag Medium (20-40 lbs) $23Euthabag Large (40-85 lbs) $29Euthabag X-Large (85-190 lbs) $39

Do you have a veterinary clinic that you would like us to notify? Please enter the name of the practice, and we will be in touch with them to let them know, or write in that you will be notifying them.*

If your pet is listed under someone's name that is not the one entered on this form, please give us that information as well, so there is no confusion in contacting the clinic.

Is there a person or clinic that referred you to our practice? If so, please let us know so that we can reach out to them in appreciation of their referral (if a particular person at a clinic let us know both their name and the clinic name, thank you)

I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above; that I do hereby give Dr. Carrie Donahue full and complete authority to humanely euthanize this pet.

I do hereby, and by these presents forever release the said doctor, her agents, or representatives from any and all liability for so euthanizing this pet.

I do also certify that this pet has not bitten any person or animal during the last ten (10) days, and to the best of my knowledge has not been exposed to rabies.

For home burials only: I hereby accept full and total responsibility for the remains after the procedure. I have read up on all applicable laws concerning disposal of remains. I understand the regulations and the inherent dangers of disposing of animals that have been euthanized with chemicals.

Signature*

Name*

First NameLast Name

Date*

MonthDayYear

Payment Options*

I will pay with cash at the time of service (invoice will be texted/emailed in advance)I will pay by check at the time of service. Please make checks out to Full Circle Vet, ahead of time if possible. Invoice will be texted / emailed in advance) No checks accepted for locations outside of Dane County or with home burial / communal cremation options.I would like an invoice emailed /texted prior to the visit with a link for credit card payment (payment must be made prior to visit)I would like a payment plan (we use Scratchpay, which offers 3 months financing at 0% interest, along with other plans). Here is a link to the Scratchpay application: https://scratchpay.com/consumer/9d42d04e8fb91981f88b026cf1565450

End of Life Care Information and Consent

Client Information

Patient Information

Procedure Information

After Care

Authorization of Procedure