Client Registration Form - End-of-Life Doula Services

Client & Companion Animal Information

Your First Name *

First

Last *

Last

Chosen pronouns (if you'd like to share)

Cell Phone (numbers only, no dashes) *

Animal's Name *

I'd love to see your favorite picture of your animal companion! Share it here.

Maximum file size: 52.43MB

Address *

Address

City

State/Province

Zip/Postal

Country

Email Address *

How did you hear about me? *

Breed or other specific details about your animal *

Weight/Sex/Age *

Household Information (please list everyone who lives in the home - animals and humans). Please list ages of animals and humans. For family members you wish to authorize to communicate with me, please provide cell phone numbers next to their names here. If there is no contact information listed for them I will be unable to communicate with them directly. *

Additional (non-household) people authorized to communicate with me on your behalf, if applicable. Provide full names and cell phone numbers for each person.

Vet & Medical Information

Vet Office/Vet's Name *

Vet's Phone Number (numbers only no dashes) *

Diagnosis or health concerns related to end-of-life (cancer, arthritis, organ failure, behavior, etc.) *

Do you have a euthanasia date scheduled? If so, please list it below. *

Yes

Euthanasia Date Is Scheduled For:

Have you and your vet completed a quality of life assessment? *

Yes

In connection with the companion animal end-of-life doula services being provided, do you authorize me to communicate with the veterinarian you identified above? *

Yes

Do you need any disability-related accommodations to fully participate in this consultation? For example, closed captioning for Zoom? Please feel free to share any information you are comfortable sharing.

Anything else we missed you'd like to share about yourself or your beloved?

If you are human, leave this field blank.

Client Registration Form – Companion Animal End-of-Life Doula Services

Client & Companion Animal Information

Vet & Medical Information

Help Me Get To Know Your Beloved Companion

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