End of Life Care Registration Client Name * First Name Last Name Address * City/State * Is there anything we need to know regarding parking or locating your home? (Example - Street/reserved parking, GPS provides inaccurate directions, hidden driveway) Please note, our van is 14 feet tall and 19 feet long! Best Contact Number * (###) ### #### Email * How did you hear about Vets to Pets? * Patient Name * Patient Species * Canine Feline Patient Sex * Neutered male Intact male Spayed female Intact female Patient Breed & Color * Patient Age/Date of Birth * Estimated Weight * Is your pet current on the Rabies vaccine? * Yes No From 1 to 10 (10 being they've needed sedation and 1 being they sit in the vet's lap) how stressed or anxious has your pet been at previous vet visits? * 1 2 3 4 5 6 7 8 9 10 I, the undersigned, certify that I am the owner (or the duly authorized agent for the owner) of the animal described above, request, consent to, and order, euthanasia to be performed on said animal. * Type your name below I can verify my pet has not bitten a person or another animal in the last ten (10) days and to the best of my knowledge has not been exposed to rabies. * Type your name below I understand that euthanasia is the act of ending the life of an animal in a painless way to prevent any unnecessary suffering. * Type your name below Would you like us to notify your veterinarian after the procedure? If so, please list the name of your veterinarian below. * I give Vets To Pets Veterinarians (their agent and representatives) full and complete authority to euthanize my pet in a humane manner and in accordance with the rules and regulations of this establishment. Furthermore, I release any Vets To Pets, their representatives and the clinic from any and all liability of said euthanasia. * Type your name below I am the owner or responsible agent for the pet(s) listed above and assume responsibility for all charges incurred in the care of this/these pet(s). I also understand Vets To Pets will collect payment during my appointment to ensure services are paid for. * I understand Vets To Pets will collect the payment in full during my appointment. We require verbal authorization prior to any photography or recording of our team. * I understand that I need to ask for permission prior to photographing or recording any Vets to Pets staff members. Vets To Pets appreciates all client feedback. If you have a concern about your recent visit, please contact vetstopetsmanagement@gmail.com. We will not tolerate negative social media posts about our services. It is required that all our staff and doctors be treated with the utmost respect. Any deviation from these standards will result in termination of our doctor/client/patient relationship. * I understand that if this occurs, the doctor/client/patient relationship will be terminated. I have fully read and understand the above terms. * What symptoms has your pet been experiencing? * When are you looking to have this procedure performed? * Do you have any cultural, religious, or other traditions, observances, or preferences that we should know about? Do you have a preferred method of contact? * Text, email, and/or call. Thank you for your submission! We will reach out via email with information about booking.
