Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Client InformationFull Name *Phone *Address *City *State *Zip Code *Email Address *Preferred Method of Contact: *PhoneTextEmailPet InformationPet's Name: *Breed *Age *Approximate Weight *Gender *MaleFemaleReproductive Status *Spayed or NeuteredIntactColoring/Specific markings Current Medical Conditions (if any)Primary Veterinary ClinicHas your pet ever shown aggression or anxiety with handling? *YesNoYes *Oral sedation medication prescribed by your primary veterinarian and/or a muzzle may be required to handle aggressive pets.How did you hear about Gentle Journey? *Internet SearchWord-of-MouthSocial MediaBoarding or Grooming LocationOtherRequested Service *Pet Hospice (Palliative/End-of-Life Comfort Care)Pain Management (Acupuncture and Laser Therapy)Quality of Life AssessmentCremation / Aftercare OptionsIn-Home EuthanasiaHome Burial and Cremation Options (cremation prices listed on our FAQ/Pricing page) *Home Burial - I will provide my own bag/boxHome Burial - Biodegradable bag provided by Gentle Journey ($20)Individual Cremation - ashes returned to me (Complimentary Metal Tin, or Walnut/Cedar Wooden Box Included. Please make selection on Cremation/Remembrance Items Form)Group Cremation - ashes dispersed in the mountains on private property in Morgan, Utah Please list any personal items to be cremated with pet (blanket, toy, collar, etc...) *Agreement *I, the undersigned, certify that I am the owner or duly authorized agent for the owner of the animal described above, and that I have the authority to make decisions regarding their care. I hereby give Gentle Journey's veterinarians full and complete authority to humanely euthanize the said animal in whatever manner they deem most compassionate and appropriate.I understand that every effort will be made to ensure my pet's comfort, peace, and dignity throughout this process. I also release Gentle Journey Veterinary Care and its representatives from any liability related to the euthanasia procedure or aftercare once my pet's remains have been transferred to the cremation service provider, Wasatch Family Pet Services.I certify that, to the best of my knowledge, my pet has not bitten any person or animal within the past fifteen (15) days and has not been exposed to rabies.Unless otherwise directed, my pet will be respectfully transferred to Wasatach Family Pet Services for cremation according to the aftercare option I have selected. If ashes or remembrance items are to be returned, I understand they will be delivered to me once the process is complete.Scheduling Requirements and Payment Agreement *My pet will be added to the Gentle Journey schedule only after all required forms have been completed, aftercare decisions have been made, and full payment has been submitted.A consultation via text, phone, or email with a Gentle Journey veterinarian will be required to discuss appropriate services for my pet.Payments are processed through a secure digital platform (Square), and a payment link will be emailed to me once all required forms have been completed.I understand and agree that:Client Initials * pet Privacy Requested Acknowledgement of Mobile Service Limitations *I acknoledge that Gentle Journey Veterinary Care provides in-home comfort care, palliative support, and humane euthanasia only, and does not provide emergency services, hospitalization, surgery, or general wellness care.I understand that Gentle Journey Veterinary Care is a mobile service and that the veterinarian may arrive alone or with a technician at their discretion. I also understand that assistance from those present may be required for positioning, restraint, or transport of pets -particularly dogs weighing over 40 pounds- to ensure safety and dignity for everyone involved.Client Initials *Consent to Treatment *I give Gentle Journey's veterinarians permission to examine, treat, or humanely euthanize my pet as requested.I have disclosed any history of aggression, fear-based behavior, growling, snapping, or biting (including during grooming, nail trims, or medical visits). I understand that undisclosed behavior risks may affect how the appointment proceeds and may require additional safety measures or assistance. If my pet is aggressive during the visit without prior notification of this behavior, the visit may need to be rescheduled until calming medications can be prescribed by the pet's primary veterinarian, and I understand I will still be financially responsible for the housecall portion of the visit, whether or not treatment is completed.Client Initials *Communication and Privacy Consent *I consent to being contacted via phone, text, or email for all communication regarding my pet's appointment, updates, and any information regarding aftercare.I understand that my personal information will only be used for communication and service coordination and will not be sold or shared.Client Initials *CheckboxesBy signing below, I acknowledge that I have read, understand, and agree to all terms in Gentle Journey's Client Service Agreement as listed on their website, as well as the payment agreement listed on this form.Signature * Clear SignaturePrinted Name *Date *Send to Myself *YesNo Submit
