Question Form

 

Please fill out the question form as best as you can, below, to assist both yourself & Dr. Susan to prepare for your appointment, or discuss details specific to your enquiry. 

 

Please either copy this document into an email to fill it out and send it back, or, print it out to scan back as an attachment, or fax it to us.

(If you are unable to scan/fax, please type an email answering the questions, thank you!)

 

ccvhs1@gmail.com  Ph: 604-314-6542   Fax: 604-940-8808 (9am - 9pm only please)

 

Thank you for answering these following questions.  This information will help me to be prepared ahead of time allowing you pet to be the focus of my time in your home.  Please answer each question with a word or a line in CAPITALS, (as my printer is only Black/white) and email or fax it back to me:

 

Part 1: You & Your Home

 

1. Your full name:                      

    Are you the legal owner, with the authority to sign legal and financial forms:

2. First and last names of your spouse or another family member who may be responsible for signing legal forms:

3. Address (include postal code):

4. Phone Numbers:

    Do you readily use text?

(I will call or text you as I am on my way to your home)

5. Email Addresses:

6. Who will be present? (Please let me know the names of others who will be present, and if family members have different last names than your own):

 

7. Will those initially present be staying for the whole procedure?  This is a very personal decision, which you may decide now or later. 

 

8. Will there be children present (young, teen, or adult)?

(If so, please discuss this with me ahead of time as I have recommendations based on my experiences) Everyone who is staying needs to be 100% in agreement and support of your decision in order for me to proceed.Please double check with all involved.  If there is any doubt with anyone who would  be present, my protocol is to have  a "quality of life" consultation first, either with your clinic veterinarian or through me as a home visit - what ever is best for you and your pet - before planning a seperate day for a planned, peaceful, home euthanasia. Quality of life exams are not routinely performed on the same day as a peaceful home euthanasia, for reasons explained under "Quality of Life" exams. 

 

Is a "Quality of Life" consultation at home needed or possibly needed before planning a seperate "Peaceful Home Euthanasia" appointment? : 

 

Is everyone who will be present in support/agreement of your decision?

 

  

 

9. Parking:  I will need to park near your door, and in a secure parking area if your housing complex has one.  If it is busy street parking or paid street parking, please allow me to park in your parking stall. Please advise me if additional parking costs need to be added to the invoice .

10. Describe the parking arrangements:

11. Driving tips for your area, recognizing your home etc. (hedge, gate, trees)

12. Please let us know if you have any specifice considerations regarding scheduling:

 

NOTE:If your home or house number cannot quickly be seen from the road when driving past, or if you are in a rural area with a long driveway, please put a marker at the end of your driveway.  Ie: a recycling bin, chair, cone, potted plant – so that I can easily identify your home - and advise me what to look for.

 

 

Part 2 – Your Pet

 

1. Your Pet’s:         

                Name: (formal and common name if applicable):

                Age:

                Breed:

                Gender:

                Weight (for sedation purposes):

                Is this weight from a vet clinic or an approximate?

                What are your pet's medical conditions, or quality of life considerations, that are part of this decision?

 

2. Previous Veterinary Clinic(s) from the past 5 years:

(I will notify them of my visit the next day)

 

I understand that Dr. Hetherington may contact my previous veterinarian to review my pet's medical history in preparation of her visit.

 

3. What is your pet’s temperament?

• How is your pet with visitors?

• Would your pet let me pet them?

IF NOT, it is very important that we discuss this prior to my visit.  My goal is for this to be a very peaceful visit.  I will Possibly need to organize additional steps, extra time, sedation etc. if I feel that this is needed. it is much better to tailor our plans to best suit your pet. 

Please provide any details that I may need to consider this:

 

4. Do you have a Veterinary Insurance Policy?  

    If so, please have a insurance claim form,  signed and  prepared for Dr. Susan to take with her. This will be faxed for you with a paid reciept in the week following. Please contact me if any delay in the reply from the insurance company.

 

 

Part 3 – After Care Wishes

 

1. Would you like me to take care of all of the after care arrangements for you (to arrange with Until We Meet Again, as explained in the overview)?:

2. If Yes,

• Do you request a Regular Cremation, where the ashes are NOT returned?:

• Do you request a Private Cremation, where the ashes ARE returned?:

 

3. For Private Cremation Only:

• Please choose the Urn Colour you would prefer (included in the cost):

                White

                Black

                Mother of Pearl

                Organza Pouch (no urn), if you would prefer to spread the ashes

• Please advise me if you would prefer a special order urn (additional cost) from the www.untilwemeetagain.ca website. If so, please give me a full description of the urn, after asking UWMAgain if it is available, and, if selected, I can add this to the invoice on your behalf. 

 

• Please type how would you like the names of your pet & yourself  to read on the certificate, which is returned with Private Cremations:

• Your pets name: 

• Name of yourself or family, eg Mary Smith,  or The Smith Family , or Greg Smith and Mary White, should include a last name : please write out your choice: 

• there are 3  options as to having your pets ashes returned to you: 

  • ​Your veterinary clinic or a clinic nearby (clinics will kindly do this as a complementary service, and i will fax them) 

  • Your home depending (on where you live and if you can be home usually middle of the day for 2-3 hour window)

  • Directly at  Until We Meet Again (North Vancouver) - their centre is very peaceful and supportive, people find great solace in collecting thier pet's ashes there, highly recommended. Open weekdays and Saturday, Sunday. 

  • Please state your preference for having your pets ashes returned: 

  • Please state the clinic name/location if you will collect ashes and/or pawprint from a clinic:

 

4. For dogs over 35lbs, I will need someone who is physically and emotionally able to assist me in carrying a stretcher. If your pet is over 50lbs, I will need a strong person to assist me who has no back problems or disability issues (family member, neighbor, friend).

Please let me know what you have arranged:

 

5. Would you like a Memorial Paw Print Casting? This can be done before either a private or a general  cremation.

If you would like a Paw Print, please let me know and fill out the form ahead of time as best you can (form is in the drop down menu above "Spawts Paw Print Keepsakes").  If you need assistance, I can help you to finish filling out the form when I arrive, but please decide on colours etc before i arrive. If you plan to make your own pawprint, please advise me as I also have suggestions. 

 

 

Forms and Payments are completed when I first arrive.

Please review the "costs" section of the "Peaceful Home Euthanasia" section, and send me any questions regarding costs, to clarify by phone and /or email,  before I arrive. There are 3 costs: the housecall, the sedation and peaceful euthanaisa, and the cremation options (plus add'l paw print option if chosen). 

 

Please confirm your understanding of any additional  costs for assistance  involving additional help needed,  large dogs over 100 lbs/giant breeds,or agressive pets,  and outline your understanding of the  additional planning/timing  considerations as to your pets  size and/or temperment (this will help us to focus on any areas we need to clarify or organize):  

 

 

Would you prefer to use cash, Visa, MasterCard, or AmEx?:

 

How did you hear about our services?

 

Are there any other questions, concerns, or special considerations you would like to discuss or let me know about?: 

 

Preferred days, time? Timeliness?: 

 

Note: Signs of when more urgency needed, to help your pet within 24-48 hrs, or sooner, are : increased breathing OUT effort (pushing in with abdomen), coughing up phlegm, frequent coughing, respiration rate over 30/min, bloated appearance, pale gums (should be bubble gum pink), cant stand up, seizures, increasing inability to get up, especially if a large dog. If i cannot  contact you or help within this period, please arrange for help via one of the emergency clinics listed on this website 

 

I routinely would like to "meet" you on the phone before arriving, confirm your information, and address any more specific questions/considerations. What are the preferred days/times/numbers to contact you?

 

Please also contact me after sending this , if you have not heard back within 24-48 hrs, depending on the timeliness. I appreciate that you are looking ahead to help your pet this way as a great kindness. 

 

Sincerely 

 

Dr. Susan Hetherington

Creature Comforts Veterinary Home Services Ltd.