Quality of Life Consent Form

Purpose of Quality of Life Assessment

I understand that Serene Passages is providing an in-home Quality of Life Assessment to help evaluate my pet’s current level of comfort and overall well-being.

Included Services

I understand that this Quality of Life Assessment includes:

• One in-home evaluation
• Review of recent history, behavior changes, and medical records (if provided)
• Discussion of Quality of Life and Pain Scales
• Short term prescriptions if the veterinarian deems those necessary for my pets health and comfort. These prescriptions will not be refilled or continued unless I am referred to my primary care veterinarian or I enroll my pet in hospice with Serene Passages.
• A discussion of care options, which may include: continued monitoring, comfort-focused (palliative) care, hospice enrollment or humane euthanasia
• A written follow-up summary and recommendations provided via email

Treatment and Care Planning

I understand that the veterinarian will discuss all findings and recommendations with me before any further services are performed. No treatments, medications, or euthanasia will be administered without my express consent.

Limitations of This Service

• This visit is focused on assessing and advising; it does not include hospice enrollment, long-term care, or the provision of ongoing prescriptions.
• If I wish to pursue hospice care following this appointment, I may discuss enrollment during the visit or follow up with the Serene Passages team within one week. I understand that enrolling in hospice will incur additional fees of $180 per month for four weekly 30 minute phone consultations.
• I understand that further in home visits will be charged at the regular rate

Financial Responsibility

I acknowledge that payment is due at the time of service and that additional services—including medications, follow-up care, or euthanasia—will be billed separately.

Collaboration & Communication

I agree to provide accurate and complete information about my pet’s health and behavior, and to maintain open communication with the Serene Passages care team.

Future Care Decisions

I understand that based on the outcome of this Quality of Life Assessment, I may choose to:

• Continue monitoring at home
• Initiate comfort-focused hospice care
• Seek care from my primary care veterinarian or specialist as advised by Serene Passages
• Proceed with humane euthanasia

I understand that Serene Passages can support me in navigating these options and that I can request further guidance at any time.