Euthanasia Consent

Euthanasia Consent:
We at Parkland Veterinary Hospital understand all too well that pets are a treasured member of our family and that losing a loved one is a very emotional process. We deeply empathize with your situation and want to do all that we can to make the grieving process as sincere and serene as possible.
Pet Information

Pet Information:*

	Please enter your pet's identification below:
Pet_Name
Species
Breed
Gender
Color
Age

Owner Information
Are you a New Client?*

Yes, I am a New ClientNo, I am an Existing Client
Full Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Owner Consent / Release
I have discussed the reasons for my pet (name listed above) euthanasia with Dr. Paredes and I am completely satisfied that humane euthanasia is the appropriate course of action. I have also had the fees explained to me and accept responsibility for payment of these fees.

I authorize Parkland Veterinary Hospital, P.A. to perform humane euthanasia of my pet (name listed above) and the proper disposal of the body as agreed upon between Parkland Veterinary Hospital, P.A and me.

I certify that I am the owner or authorized agent of the above-mentioned pet. I assume responsibility for the decision as well as all charges incurred for this animal.
To the best of my knowledge, this pet:*

has not been exposed to any animal that is likely to have rabies
Also, to the best of my knowledge, this pet:*

has not bitten any person or animal in the past 14 days
CREMATION OPTIONS:*

I WILL CARE FOR THE REMAINS (TAKE THE BODY WITH ME)MASS CREMATION (NO REMAINS BACK)SCATTERING TUBE BUT NO URN - PRIVATE CREMATION (Ashes Returned)STANDARD ROSEWOOD URN - PRIVATE CREMATION (Ashes Returned)CUSTOM URN AT ADDED COST - PRIVATE CREMATION (Ashes Returned)
$ Choice of CUSTOM URN (Any Urn other than the standard Rosewood Urn) *
NAME PLATE

Maximum 3 lines and up to 26 characters on each line
Name Plate Line 1:*
Name Plate Line 2:*
Name Plate Line 3:*
ADDITIONAL OPTIONS:

I WOULD LIKE MY PET’S PAW PRINTS (Free of charge if cremated)I WOULD LIKE A LOCK OF MY PET’S HAIR (Free of charge at hospital)
Signature*

Clear
DateTime
OFFICIAL USE ONLY

Veterinarian Performing Procedure: _____________________

Pronounced: Date: ____________ Time: ___________

Comments: __________________________________________
Should be Empty:

Euthanasia Consent:

Pet Information

Owner Information

Owner Consent / Release

NAME PLATE