Euthanasia Authorization Form- Easton

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: *
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. 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 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
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Euthanasia Authorization Form

COVID-19 Acknowledgement