Book a Euthanasia Appointment

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Pet's Name *

First Name

Last Name

Weight Measurement

Kg

Lbs

Preferred Date 1

7 days a week

MM

DD

YYYY

Prefered Time 1

Hours: 4pm to 9pm

Hour

Minute

Second

AM PM

Preferred Date 2

7 days a week

MM

DD

YYYY

Prefered Time 2

Hours: 4pm to 9pm

Hour

Minute

Second

AM PM

*Please Read *

I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at VHCS and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly service charge.

YES

This form will be printed off for you to sign in person during the appointment. *

I, the undersigned, am the owner or duly authorized agent for the owner of the pet described below and I hereby consent to and order humane euthanasia to be performed on my pet. I give Veterinary Home Care Services full and complete authority to euthanize said pet in a humane manner. Furthermore, I release Veterinary Home Care Services from any and all liability of said euthanasia.

I agree

To the best of my knowledge and belief, my pet has not bitten any person or animal during the past fifteen (15) days and has not been exposed to rabies. *

True

False

Regarding after care, I select the following option: *

Group Cremation (no return of ashes)

Private Cremation and return of ashes

No Cremation, I will be taking the pet home