Consent for Euthanasia and Aftercare

Consent for Euthanasia and Aftercare
Name of legal Owner or authorized agent signing form.*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Pets Name (please enter your pets name as you would like it spelled and/or written for services requested below): *
Please select below to confirm your authorization and that the following statement is true:*

I hereby request and authorize euthanasia for the above referenced patient. I am the legal owner or agent for this pet and fully authorized to approve the procedure. This animal has not bitten any person or animal within the previous ten (10) days. I understand that euthanasia will be performed in a humane and caring manner.Other
Signature*
Date*

MonthDayYear
Date
After Care Instructions:
I Request the following aftercare:*

Return remains after euthanasia for burial at home.Cremate remains after euthanasia in a communal (non-private) cremation.Cremate remains after euthanasia in an individual (private) cremation and return the ashes to me.
I also request the following:*

Clay Paw Print (one) (white air-dry foam clay in faux leather case)Ink Paw Print (one)Decline any paw printsFur Keepsake Keychain (max of 1 per family) (color may vary)Decline Keepsake KeychainOther
I also request the following:*

Terra Cotta Clay Paw Print (one) and fur clipping (will arrive when your pets remains are returned to the Clinic)Ink Paw Print (one)Decline any paw printsFur Keepsake Keychain (max of 1 per family)Decline Keepsake KeychainOther
Please allow at least 48 hours for your paw print(s) to dry. You can pick them up any time after this, Monday through Friday, 8:00am until 6:00pm.
Please allow at least 48 hours for your paw print(s) to dry. You can pick them up any time after this, Monday through Friday, 8:00am until 6:00pm.
Please see the bottom of this page and select which urn you would prefer (no additional cost):*

Cedar Memorial UrnSerenity Photo UrnHand-Carved Rosewood UrnRemembrance UrnBlue Decorative Metal UrnTan Decorative Metal UrnBio Remembrance UrnScattering Tube
Would you like a name plate at no additional charge?*

NoYes
Would you like this urn engraved with your pets name at no additional charge? *

NoYes
Other services requested at an additional cost (please call for pricing):*

Additional Clay Paw Print (white air-dry foam clay in faux leather case)Additional Ink Paw PrintWood Urn Etching (name only) instead of name plate *Max of 20 characters** This option is not available with the Hand-Carved Rosewood Urn**Additional Engraving (beyond pets name) **Max. of 4 lines with 20 characters per line**No Additional Services RequestedOther
What would you like the engraving to say?*
When your pet's remains have been returned to the clinic, how would you like to be notified?*

CallText
What phone number would you like us to use? *

Area CodePhone Number
Please type your initials to confirm your selections above:*
Should be Empty: