HAMILTON - NIAGARA VETERINARY MOBILE EUTHANASIA SERVICE: EUTHANASIA APPOINTMENT REQUEST AND AUTHORIZATION

Client Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email *

example@example.com

Phone Number *

Area Code Phone Number

Pet Name *

Species *

Dog Cat

Breed *

Age *

Weight (Approximate) *

Color *

Gender *

Male Female

Spayed or Neutered? *

Yes No

Reason for Euthanasia? *

Primary Veterinarian

Veterinarian's Phone Number

Area Code Phone Number

Please select one of the following: *

Private Cremation Communal Cremation At Home Burial Unsure - Please use comment section below

Unsure comments or questions

I certify I am 18 years old or older and the owner or authorized agent of the owner, for the above named animal.

I hearby request and fully authorize Hamilton - Niagara Veterinary Mobile Euthanasia Services to perform euthanasia for the above referenced patient.

I confirm that this animal has not bitten, seriously scratched or exposed any person or animal to Rabies within the previous fifteen (15) days.

I understand that euthanasia will be performed in a humane and compassionate manner.

Fees for these services has been explained to me and will be collected at the time of service or before if I prefer to take care of finances prior to the appointment.

To the best of my knowledge, the information I have provided on this form is accurate and true.

Date *

Date

Client Initials *

HAMILTON - NIAGARA VETERINARY MOBILE EUTHANASIA SERVICE: EUTHANASIA APPOINTMENT REQUEST AND AUTHORIZATION

After Care Options

Euthanasia Authorization