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Hospice / End-of-Life questionnaire
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Client Name
*
First
Last
Email
*
Pet's Name
*
Phone
Who will be the primary caregiver? Please provide their name and phone number.
If the primary caregiver is unavailable, who else is allowed to make critical decisions? Please provide their name and phone number.
What is the caregiver’s preferred mode of contact
Email
Text
Phone
What are the goals or expectations you have for your pet’s care?
Which form of medication is easiest to give to your pet.
Pills
Liquids
Injections
Are there any environmental concerns that could affect the care of your pet? (e.g., large number of stairs to yard, fear of needles, behavior issues)
Are there any other limitations to care?
Are there any religious or spiritual beliefs you would like to share as part of your pet's care?
When it comes time for the final goodbye, do you have any special wishes you would like us to know about? (e.g., collect paw print, nose print, lock of fur?)
10) What are your preferences for aftercare? (e.g., home burial, cremation)
Submit
