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Euthanasia Request
Complete the form below to request a euthanasia appointment for your pet.
Owner/Agent (first name)
Owner/Agent (last name)
Email
Phone
Home Address
Street Address
City
State
Post code
Different location for euthanasia?
Yes
No
If you'd like to arrange the euthanasia appointment for a different location (eg, the beach), please select yes.
Euthanasia location
Preferred Euthanasia Appointment Date
Family members
Pet's name
Pet's age
Pet's Breed
Pet's weight
Pet's Sex
Male
Female
Usual Clinic
Reason for requesting Euthanasia
After care request
I choose Private Cremation
I choose Group Cremation
I choose to retain my pet for burial
I have made my own collection arrangements
Owner certification
(Required)
I certify that I am the owner, or authorised agent of the owner, for the above named animal. In being the owner/agent for this animal, I do hereby give Dr Lloyd's Mobile VetCARE full and complete authority to perform home euthanasia services.
Owner release
(Required)
I release the above named animal to Dr Lloyd's Mobile VetCARE for home euthanasia - humanely terminate life. To the best of my knowledge, the information I have provided on this form is true.
Signature
