Euthanasia Information Request Form
We are saddened that you are having to make this difficult decision for your beloved pet. In order to provide you the most accurate estimate and to better assess your needs, we require the following information. 

Please remember that, if you aren't fully sure about your decision, we offer in-home quality of life discussions and hospice care. You may also consider looking over the Lap of Love Quality of Life Assessment (https://www.lapoflove.com/quality-of-life-assessment). For more information regarding other services, visit saltandlighthousecallvet.com. Our Business Hours are Monday - Friday 8:00am - 5:00pm 

We will be praying for you during this time. 

Please note that your request may not be answered immediately, but will be answered within 1-2 business days. If you are a current client, please reach out through call (leave message) or text. 

*Disclaimer: We are unable to provide emergency care and are limited on providing urgent care. If you are experiencing an emergency with your pet, please seek help through an alternative clinic. If you are experiencing an urgent situation with your pet, please fill out this form, then reach out through call or text.
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Email Address *
Phone Number (format XXX-XXX-XXXX (INCLUDING THE HYPHENS) , otherwise it is difficult to read and an incorrect number may be contacted)  *
What is the address where your pet is located? Please include number, street name, city and zip code *
Does Google Maps take you directly to your house? *
Is your house clearly marked with your house number? If not, can you provide a detailed means of identifying your house?
*
What is your preferred medium of contact?
 *
Please list your pet's name, type (dog, cat, etc.), breed, color, male/female (spayed/neutered), and age. *
Is this euthanasia urgent (needed within the next 2 days)? *
What is the approximate weight of your pet?  *
Where can we call to get previous veterinary records?
What are your wishes regarding your pet's remains? We can more fully discuss these options, but each option has a different cost. *
Has your pet ever shown signs of aggression when in an uncomfortable situation such as a veterinary appointment? If so, would you consider giving a recommended pre-sedation protocol to facilitate the process with less stress? *
What is your preferred day(s) of the week for a house call?
 *
Required
What is your preferred time(s) of the day for a house call? *
Required
We accept the following payment options. Please indicate which you will most likely be using.  *
Required
I would like an estimate sent prior to setting up an appointment.  *
How did you hear about Salt and Light House Call Veterinarian?
If you were referred by a current client, please list them here, so that we can thank them!
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms