At Home Euthanasia Authorization Form

Home Euthanasia Authorization

We are so Sorry. Please know that we are Here to Support you and your family through this tough time.

Filling this out ahead of the appointment will allow us to concentrate on you and your loved one.

Please let us know how we can help. Thank you.

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Appointment/Desired Appointment (if you don't know yet, that's ok - just put that as it will help us to understand how to help you the best!) *

Any details we need prior to arrival? *

Pet Name, Age, Breed, Approximate Weight *

Any previous anxiety or aggression at the vet? *

Is there anything that has made home visits in the past successful? *

Any concerns or questions you have about home euthanasia? *

Do you consent to treatment by Wildflower Veterinary Mobile Services, PLLC during the appointment you have requested? *

Yes No

Do you confirm that a legal family representative above the age of 18 will be at the home for the scheduled visit? *

Yes

I confirm that the pet we are treating has not been in contact with Rabies, or bitten anyone in the last 10 days. *

Yes No (has been exposed or bitten someone)

We have elected the following for aftercare: *

Electronic Signature & Date *

Know that we are thinking of you.

Submit

Are you looking for a hospice or home euthanasia appointment? Know that we are so sorry - please select from the options below:

Appointment request:

Hospice Consult Request

Home Euthanasia Request

Know that we are thinking of you and your family during this tough time. There is no good way to say goodbye, but being able to be together in the comfort of your own home is one of the sweetest gifts. We are glad to help with any questions you may have.

Thank you for letting us help walk these last few steps with you and your family - Dr. Desiree & the Wildflower team

email for questions:

Email Link

Emails are answered or returned during normal business hours when we are not in other appointments. Please provide as much information as possible to help us serve you in a more timely manner.

ADDRESS:

(MAILING ADDRESS ONLY)
Wildflower Veterinary Mobile Services, PLLC
8301 Lakeview Pkwy
Suite 111-216
Rowlett, TX 75088

Please note, this is a business address and patients are not seen here.

Wildflower proudly serves the communities of the Northeast DFW Metroplex including Rowlett, Rockwall, Wylie, Sachse, Murphy, Plano, Allen, Garland, East Dallas, Farmersville, McKinney, Melissa, Anna, Blue Ridge, Merit, Greenville, Celeste. (General borders are Dallas North Tollway on West, I-30 on South, Greenville area to East, and Sherman to North) As time allows, we would be glad to travel outside the normal service area (additional house call fee).