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COSMIC LIGHT

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Home Euthanasia
Hospice consultation
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Grief Support

Patient form

in home euthanasia preparation & planning video (shorts) series

* Indicates required field

Name *

First

Last

Pet's name *

Pet's breed *

Pet's weight *

Pet's age *

Pet is male or female *

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How soon you need help *

Services needed *

Return of ashes *

Add on packages *

Select all that apply to your pet *

difficulty breathing / respiratory distress unable to move/walk/stand anxious poor quality of life cancer diagnosis incontinence (urinary/fecal) anorexia (not eating) renal/kidney disease or failure heart disease or failure behavioral aggression (otherwise physically healthy) slipping/falling emergency/traumatic event A veterinarian has recommended euthanasia for my pet A veterinarian has given my pet a poor prognosis I have financial constraints providing care

Pet's medical condition (if known) or reason for euthanasia *

Should we notify your primary veterinarian if we euthanize your pet? *

IF yes, provide your pet's primary veterinary clinic name & location *

Submit

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Cosmic Light | End of Life Care for animals

home
Schedule an appointment
Contact us | Patient Form
Home Euthanasia
Hospice consultation
About Dr. Curtis
Services
Consent form
Grief Support