Our House Call Vet : Euthanasia / Aftercare Form

Owners full name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Number *

area codenumber

e-mail address*

Pets Name *

Breed and color*

Weight*

Pets age*

Reason for euthanasia (diagnosis and/or symptoms)*

Regular Veterinary Hospital name*

How is your pet with strangers? At the veterinary clinic, do they bite, scratch, jump or try to run away or hide? Do they usually need anxiety medication to go to the vet? Do they need a muzzle at the vet?*

For aftercare, do you want a private cremation (where you get the ashes back); or a group cremation (where you do not get the ashes back)*

Specifically, when are you requesting our services for:Today? Tomorrow? Later this week? Next week?*

As the owner or owner's representative, I am authorized to sign for this pet's euthanasia and aftercare. I certify that this pet has not bitten a person or another animal within the last 10 days, is not under quarantine, and has not been exposed to rabies. I give my authorization for Dr. Mazzola and her agents to proceed with the euthania and/or aftercare as specified.

Signature to be signed at the time of the appointment