Euthanasia Consent Form on Cape Cod, Barnstable County

Today's Date*

Pet Owner's Name*

First Last

Spouse/Partner's Name (if applicable)

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone - Best contact number*

Email*

How Did You Hear About Us:*

Pet's Name*

Pet's Age*

Dog or Cat*

Dog
Cat

Pet's Weight (in pounds)*

Breed & Color*

Male or Female / Neutered or Spayed*

Please list Veterinarians and Pet Care Professionals who have seen your pet within the last three (3) years.

I also certify to the best of my knowledge, the animal described above has not bitten, scratched, or otherwise potentially exposed any person or other animal to rabies in the past ten (10) days. I understand that if the animal described above has bitten or otherwise potentially exposed any person within the time specified, a rabies test must be performed

I understand that euthanasia is the act of ending the life of an animal in a painless way to prevent any unnecessary suffering. To the best of my knowledge, the information I have provided is accurate and complete. I understand that my wishes may be carried out immediately upon my signing this agreement. Fees for these services have been explained to me, and I assume full responsibility for all charges applicable to such services. I have carefully read and fully understand the foregoing provisions.

After Care Arrangements:*

I wish to have Litchfield Animal Wellness arrange for my pet's aftercare.
I will handle and take full responsibility for all after care arrangements myself. I am aware of any applicable laws and regulations regarding the burial of a pet’s body and understand caution should be taken when disposing of animals euthanized with drugs/chemicals.

If you chose aftercare, please select one of the following:

Individual Cremation - (ashes returned in wooden urn) [pricing varies]
Group Cremation - (NO ashes returned) [pricing varies]

If you chose Individual Cremation, please select one of the following:

Bamboo Wooden Urn
Cedar Wooden Urn
Carved Wooden Urn

Scroll to bottom of page to see the urn options. Urn will be size appropriate for remains.

Additional Options Available With Aftercare:

Clay Paw Print Impression + $65 ea
Ink Paw Print + $35 ea
Ink Nose Print + $35 ea

If multiple of any memorial item is desired, please let Dr. Monte know. Scroll to bottom to see the prints options.

Financial Policy*

I agree to the Financial Policy.

Thank you for choosing Litchfield Animal Wellness.
Our Mission is to provide the very best healthcare and service to our patients and their owners.
One way we accomplish this is to offer clients easy payment options.
Accepted Methods of Payment:
✓ Cash
✓ Check (Copy of Driver’s License required)
✓ Visa, MasterCard, American Express, Discover Card
Credit Cards are processed securely via Square
Policy Information:
Payment is expected at time of service. We prefer to devote our time to caring for our patients, as opposed to managing accounts.
Credit Card information can be called into the office and will be kept on file and will be charged if other payment arrangements were not discussed. Credit Card receipts can be emailed to the cardholder.
There will be a $75.00 fee for all returned checks.
A house call fee may be charged to any client that misses an appointment.
A $100.00 fee may be charged to any client that does not give at least 24 hours notice to cancel an appointment.
Agreement:
By checking above, you agree to the terms of payment.

Our Commitment to a Safe and Respectful Environment*

I agree to the Client Conduct Policy

Client Conduct Policy
Providing in-home veterinary care—especially end-of-life care—requires a calm, supportive, and respectful setting for families, patients, and our team. We are deeply committed to maintaining a safe environment during every home visit.

To protect that environment, we maintain a zero-tolerance policy for abusive or disruptive behavior. The following behaviors are not acceptable:
•Verbal or physical abuse
•Threats, intimidation, or aggressive conduct (direct or implied)
•Yelling, screaming, or hostile outbursts
•Harassment of any kind
•Discriminatory remarks or actions
•Profanity, name-calling, or abusive language directed toward staff
•Malicious or harmful statements about others
•Aggressive or menacing behavior toward people or pets
•Any other behavior that disrupts or compromises the safety and well-being of our team

If a client engages in any of the behaviors listed above, services will be discontinued immediately. Medical records will be forwarded to the address on file, and we will be unable to provide future services to the client or members of their household.

We understand that emotions can run high during difficult moments, and we approach every visit with compassion and empathy. We sincerely appreciate your cooperation in helping us maintain a respectful and supportive experience for everyone involved.

Thank you for your understanding.

Legal Ownership*

I certify that I am the legal owner (or duly authorized agent for the owner) of the animal described above, and do hereby give Dr. Paula Monte, Litchfield Animal Wellness, and any authorized agents, staff, or representatives full and complete authority to euthanize and handle after-care of said animal in a humane manner. I hereby forever release and hold harmless Dr. Monte, Litchfield Animal Wellness, and any authorized agents, staff, or representatives from any and all liability for euthanasia and disposal of said animal.

Signature

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