AUTHORIZATION TO PERFORM EUTHANASIA

Owner Name*

First NameLast Name

Pets Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

I certify that to the best of my knowledge that my pet has not bitten any person during the last ten (10) days, and has not been exposed to rabies.*

Yes, My pet has bitten a person within the past 10 days.No, My pet has not bitten a person within the past 10 days.

I understand that if my pet has bitten a person within the past 10 days my veterinarian is obligated to report the bite to animal control and submit samples to the Michigan Department of Health to test my animal for Rabies. This expense will be in addition to the cost of euthanasia. Please sign your name to acknowledge your understanding of the above. You may sign your name using your mouse or your finger depending on your device*

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Procedure*

Are you going to be present for the Euthanasia?Are you going to drop off your pet for the Euthanasia?

Burial*

Noah’s Communal Cremation – no cremains back. Your pet will be cremated with other pets on the hearth, the cremains are buried at the memorial garden at Noah's Pet Cemetery.*Noah’s Semi-Private Cremation – cremains returned in decorative tin. Your pet will be cremated with one or more other pets. Each pet is identified and placed in its own location on the hearth; the pets are not mixed together. Noah's assures you the cremains you receive back are that of your pet.*Home Burial- Owners will have the following options when arriving at the clinic: 1) Please wrap my pet in a sanitary bag for transport 2) I would like to purchase a Euthabag Home Burial Bag for transport ($25.00) or 3) I have provided staff with a box for transport. Please note pets will be wrapped in a sanitary bag prior to placement in box.

Other Options*

Clay Paw Print Impression- this service is not available with home burial. ($15.22 performed by Noah's Pet Cemetery)PawPal- Paw Print Impression (performed at Jelsema Vet Clinic) ($29.50)None of the above

*Please note that prices for euthanasia and cremation vary based on the size of your pet.

The euthanasia procedure at Jelsema Veterinary Clinic is performed with as minimal stress as possible for your pet. If you choose to be present for the procedure we have you bring your pet into an exam room where a technician will review your preferences and discuss any questions you may have regarding the procedure. We will then bring your pet to the treatment area where a catheter is placed into your pets leg for administration of medications. This allows us to confirm that we have proper vein placement and also allows you the opportunity to hold your pet during the injections if you desire. Pets that are overly anxious or disoriented may be administered a sedative to alleviate the stress. Your pet is then returned to you so you may have some quiet time before we say our final good byes.

The doctors at Jelsema Veterinary Clinic will then join you and our technician in the room and answer any further questions that you may have. We then will begin by injecting a sedative into the catheter port so your pet will fall fast asleep. This assures us that they will feel no pain during the procedure or dysphoria. The next injection will be the injection of euthansia solution. This is injected directly into the cather port and then followed with a syringe of sterile saline. This medication acts quickly and your pet will be at peace.

You are welcome to stay within the room for as long as you like following the procedure to say goodbye. When you are ready, you may leave and we will prepare your pet for burial or cremation.

I, the undersigned, certify that I am the owner or duly authorized agent for the owner of the above stated pet; that I hereby give Dr. Terry Jelsema or his representatives full and complete authority to euthanize and dispose of said animal in a humane manner. I release the doctor and/or representative from any and all liability for euthanasia of the said animal.*

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