Service Inquiries Client Form Name of Primary Veterinarian Clinic Name Clinic Phone Number Clinic Email Address Name of Client (registered owner on file, who will be signing the euthanasia consent form) Family Members (names of any secondary owners that may be present for euthanasia, ie. spouse, children etc.) Primary Contact Phone Number Secondary Contact Phone Number Address Email Address Name of Patient Age Species Breed Color/Markings Gender Is the Patient Spayed/Neutered?YesNo Patient’s Weight Brief medical summary and reason for euthanasia Any history of seizures, heart disease, lung disease, increased respiration rate, or labored breathing? NoYes How would you like us to proceed? Please email me to schedule or confirm an appointment.Please call me to schedule or confirm an appointment.I will contact you when I am ready to schedule an appointment.
