Please enable JavaScript in your browser to complete this form.Email *Owner's Name *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOther family members (names and ages) and petsPhonePet's NamePet's Date of BirthWho is your primary veterinarian? Please list any other veterinarians who care for your pet.Family's Needs, Beliefs, and GoalsWhat brought you to seek our care or reach out to us?What do you feel are your biggest challenges and unanswered questions?What is your experience with hospice care for a pet or person?What are your beliefs regarding euthanasia vs. hospice supported natural death?Disease Process and Illness TrajectoryDescribe how your pet was diagnosed and has been treated so far. How have you been affected by this?What is your understanding of your pet's disease and how it may progress?What medical options have you been offered thus far?What signs of illness or discomfort are you seeing now?Quality of LifeList 5 things your pet enjoyed prior to the illness.Rate your pet's current quality of life on a scale of 0 to 10. Selected Value: 1 1 being no quality, 10 being best quality.What are your reasons for giving this number? What can be done to better meet your pet's quality of life needs?What number would you ascribe to your pet for pain using the BEAP scale? Selected Value: 1 How willing would you be to take on the life your pet is living right now?Treatment Plan ConsiderationsWhat medications is your pet currently taking?What types of medications do you think your pet would be willing to accept?Pills/tabletsLiquid by mouthFlavored chewsTransdermal MedicationsInjectable MedicationsOtherIf other, please specifyWhat are your financial concerns surrounding the end of life care plan?Where would you like your pet to receive most of her treatment (home, hospital, etc)?What types of complementary medications would you be interested in (massage, acupuncture, etc)?What are your plans in case of emergency or crisis?What types of diagnostics/testing would you be interested in pursuing? How does your pet tolerate testing (blood work, radiographs)? Where would you prefer to have tests done if possible?What does your pet eat? How much food and water are they drinking?Do you have any upcoming travel plans?Environmental AssessmentWhere does your pet struggle with mobility in the home?Floors (traction, slippery)Stairs (can they go up/down without assistance)Thresholds/Dog Doors (can they step through doorways without stumbling)Clutter in main walkways (do they stumble or trip over objects)Food and Water bowls (at correct height, good traction)Dog Beds (able to get in and out of their bed)Furniture (can they get on/off easily)External pathways (non-slip, free of clutter, not too steep)Car rides (get in and out with ease, settles down once in readily)OtherIf other, please specifyWhat difficulties are you having in keeping your pet clean and free of odor?Preparation for DeathWhat concerns do the people around you have as your pet nears his/her death? If you have children, what level of involvement do you see them having as your pet passes away?Who will be present at your pet's passing?What would be the ideal location for your pet's passing?What is your preference for how your pet's body will be handled after death?Home burialBurial in Pet CemeteryPrivate Cremation with Ashes returnedCommunal Cremation (no ashes returned)OtherIf other, please specifyDo you wish to have a ceremony before or after your pet's passing? Would you be interested in grief counseling or spiritual support?What are your previous experiences with euthanasia or natural death?What questions do you have around the active dying process? Euthanasia?When do you think it might be time to euthanize? Why? *SubmitSave and Resume Later Heads up! Saving your progress now will store a copy of your entry on this server and the site owner may have access to it. Continue Go Back Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted. Copy Link Email * Send Link
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