Euthanasia Consent Form | Wholistic Housecalls

Caregiver/Agent First name

Caregiver/Agent Last name

Pet Name

Euthanasia price is based on weight: 0-50lbs $350, >50lbs $400

Pet Weight

0-25lbs

26-50lbs

51-100lbs

101lbs +

Caregiver Address

Additional Address notes (Please add directions if the place is hard to find, gate code, etc.)

Email

Caregiver Number

I certify that I am the caregiver or authorized agent of the caregiver of the patient listed below. As the caregiver or agent, I herby give consent to Wholistic Housecalls LLC to perform euthanasia services, therefore terminating life of the pet listed below. This procedure has been explained to me.

I accept the charges for this service listed above. An emergency request Fee: $50 added for same day bookings. Additional charges and regulations for aftercare were discussed. I release the pet listed below to Wholistic Housecalls for:

Euthanasia - humanely terminating life

Aftercare Options

Due to staffing and logistics I can no longer offer cremation of patients weighing greater than 80lbs.

Option 1: Pets left in care of caregivers after the euthanasia for home burial

Option 2: Private cremation

Each pet cremated individually. Ashes will be returned to your home in an urn: Dark Wood, Light Wood, and Metal Tin options available.

Cost based on pet weight:

0-25lbs $130, 26-50lbs $160, 51-80lbs $200

Option 3: Communal Cremation

Pets are cremated with other pets and ashes are spread together over green space. Ashes will not be returned to you.

Cost based on pet weight:

0-25lbs $50, 26-50lbs $75, 51-80lbs $100

I choose Option 1 to keep my pets body for burial or self-delivery cremation.

I choose Option 2 Private cremation- the ashes are delivered to my residence in 1-3 weeks.

I choose Option 3 communal cremation - the ashes are not returned to me.

Do you wish to donate towards The Gray Muzzle Project, a 501(c)3 non profit dog sanctuary with a mission to provide hospice care and forever homes to special needs and senior dogs on the Olympic peninsula? For more information please visit www.thegraymuzzleproject.org

Donation amount:

Payment Options

I choose to prepay with a card via square (a secure platform). If this option is chosen an invoice will be prepared and emailed to email the address listed on file.

I choose pay at the visit. Payment options include Cash, Check, or Credit Card (all major Credit Cards are accepted).

To the best of my knowledge, the information I have provided on this form is true. I do certify that my pet has not bitten, seriously scratched, or exposed anyone to rabies within the last 10 days. I understand that my wishes will be immediately carried out upon signing this agreement. Fees for these services have been explained to me and will be collected at time of service.

Caregiver/agent Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Today's Date