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: *

Would you like a clay paw print (made at the crematorium, possible with communal or private cremation) - $35 each *

Electronic Signature & Date *

Know that we are thinking of you.

Submit

Quick Links:

Appointment request:

Hospice Consult Request

Home Euthanasia Request

email for questions:

Email Link

Appointments are seen evenings and weekends.

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.

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