Euthanasia And Disposition Consent Form printable pdf download

EUTHANASIA and DISPOSITION CONSENT FORM

Name: ____________________________________________________________________________

Address: __________________________________________________________________________

City: _________________________________________________ Zip: ________________________

Phone:_________________________________ Email: _____________________________________

Animal’s Name: ___________________________________ Sex: M F Spayed/Neutered? Yes No

Breed: ________________________________________ Approx. Age:_________Weight: _________

Reason for euthanasia: ________________________________________________________________

Primary veterinarian(s): _______________________________________________________________

How did you hear about us? ___________________________________________________________

If seen online, circle all that apply: Directory listing by state; Google/bing search; Yelp; Other

We will send a fax to your veterinarian to update them about your pet’s passing. Is there anyone else

you would like us to notify? ___________________________________________________________

BODY DISPOSITION REQUEST

_____ I will arrange my own aftercare service. If I choose to bury my pet at home, I understand it is

my responsibility to contact my local city for regulations.

_____ Common burial (unmarked communal grave on protected pet cemetery grounds)

_____ Common cremation (ashes are buried on protected pet cemetery grounds)

_____ Private cremation (return of ashes in a cherry box with engraved name plate)

I would prefer the remains to be:

_____ Shipped (signature required)

_____ Personally delivered (where available)

_____ I will pick them up at the crematory

Engraving: ___________________________________________________________________

___________________________________________________________________

_____ Clay Paw Print Keepsake (Included w/ private cremation. $20 w/ common cremation or burial)

--I certify that I am the owner or authorized agent of the owner, for the above name animal and hereby

give A Gentle Farewell and its Doctors full and complete authority to perform euthanasia (humanely

terminate life) of my pet. Arrangements for aftercare will be based on the wishes of the owner/agent

and documented above.

--To the best of my knowledge, the information I have provided on this form is true. I do also certify

that this animal has not bitten any human or other animal within the last 10 days (this is a legal point

regarding Rabies).

Owner/Agent signature: _____________________________________________ Date: ____________

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Office Use Only

Sedation: _______________________ Euthanasia __________ Time: _________ Date:___________

Clinician’s signature ____________________________

D__ F__ C__ Asst_____

A Gentle Farewell

P.O. Box 308 Elyria, OH 44035

440-452-3422

Euthanasia $_______ Aftercare $ _______ Misc $ _______ Total $ _________

Cash Check Credit

Euthanasia And Disposition Consent Form