Owner/Agent First name

Owner/Agent Last name

Pet Name

Pet Weight

0-25lbs

26-50lbs

51-100lbs

101lbs +

Owner Address

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

Email

Owner Number

I certify that I am the owner or authorized agent of the owner of the patient listed below. As the owner 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, $350. Additional charges and regulations for aftercare were discussed. I release the pet listed below to Wholistic Housecalls for:

Euthanasia - humanely terminating life

Aftercare Options

Option 1: 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, 51-100lbs $200, 101lbs +: $250

Option 2: 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, 51-100lbs $100, 101lbs + $125

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

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

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

Choose included urn option:

Light Wood

Dark Wood

Paw Print Metal Tin

Paw print or nose print?

Yes

No

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.

Owner/agent Signature

Today's Date

Euthanasia Consent Form

Aftercare Options

Payment Options