Euthanasia Authorization Form
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Patient Name
*
Species
*
Breed
*
Sex
*
Primary Color:
*
I certify that to the best of my knowledge the said animal has not been exposed to rabies.
*
Yes
No
I certify that to the best of my knowledge the said animal has not bitten any person or animal during the last ten (10) days.
*
Yes
No
My pet has bitten a person and/or animal during the last ten (10) days. Rabies testing is required by law and there are fees associated with this test.
*
Person
Animal
Not Applicable
Please confirm your choice for care of your pet's remains:
*
Private Cremation- Ashes Returned
Communal Cremation- No Ashes Returned
Client to Take Remains
Client to Make Arrangements with another Agency
What telephone number would you like us to call when your pet's remains are ready to be picked up?
-
Area Code
Phone Number
If making other arrangements, what agency are you using?
*
I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above, that I do hereby give the doctors of Easton Animal Hospital permission to euthanize and arrange care of said animal in a humane manner the doctors of Easton Animal Hospital, their agents, servants or representatives deem appropriate. I also release the doctors, Easton Animal Hospital, their agents, servants and representative from any and all liability for so euthanizing and disposing of said animal.
*
I understand and agree
By signing on the bottom of this page, I understand this to be my expressed written consent for the euthanasia and aftercare choice I have selected.
*
Clear
Today's Date:
*
-
Month
-
Day
Year
Date
COVID-19 Acknowledgement
For the protection of both our team and clients, have you been exposed to COVID-19 or know anyone who has or is currently showing symptoms?
*
Yes- We can still provide services. Please give us a call at your earliest convenience.
No
For the safety of our team and clients, we require a face mask to be worn when you enter our building.This mask must stay on the whole time you are in the building. Please select one of the following:
*
Yes, I have a face mask
No, I need a face mask
Have you traveled outside the United States of America or the state of Ohio within the last 2 weeks?
*
Yes
No
I understand that to help decrease the spread of possible contaminants, my pet's personal items, including but not limited to: collar, leash, carrier, cages, pet clothes, blankets, muzzles, etc. may remain in the vehicle and I allow Easton Animal Hospital to use their own items to transport and restrain my pets.
*
Accept
Submit
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