Quality of Life Consultation & Potential Euthanasia Intake Form:
Is Dr. Stanley the right fit for you? Dr. Stanley understands how difficult this decision can be and will always provide an exam and consultation to discuss your pet's condition and quality of life before euthanasia is offered. As an integrative medicine practitioner, Dr. Stanley may have tools available to help extend your pet's quality of life that other veterinarians have not offered. If you know that you would like to pursue euthanasia before a quality of life exam is performed and all options are discussed, Dr. Stanley is not the right fit for your family. While it is with a heavy heart that Dr. Stanley offers this service, he is grateful to be able to provide a peaceful transition for your pet in the comfort of your home. Euthanasia services are not available for behavior problems or treatable ailments.
Urgency level
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I need assistance today
I need assistance in the next couple of days
Not urgent, but it seems like my pet's time is limited
Client Information
Full Name
*
First Name
Last Name
Address for the house call:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Can you receive text messages and do you consent to receive appointment information and doctor communications?
*
Yes
No
E-mail
*
example@example.com
Special arrival instructions/requests:
Gate codes, parking details, text on arrival, apartment and building numbers, etc.
Patient Information
Patient Name:
*
Information regarding your pet's condition:
*
Please provide a detailed description. The more information the doctor has the better.
Species:
*
Please Select
Canine
Feline
Reptile/Amphibian
Small Mammal
Bird
Breed/Type:
*
For exotic animals, please be as specific as possible.
Color/Markings:
Sex:
*
Please Select
Male (neutered)
Male (intact)
Female (spayed)
Female (intact)
Juvenile/Indeterminate
Approximate age or birthdate:
*
Please include units, i.e. years, months, weeks
Approximate weight:
*
Please include units, i.e. lb, oz, g
Previous records:
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Request for remains:
*
I will keep the remains for home burial or make my own arrangements.
I would like Dr. Stanley to take my pet for group cremation (no ashes returned).
I would like Dr. Stanley to take my pet for private cremation (ashes returned).
Anything else you would like the doctor to know prior to the visit:
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Should be Empty: