Consent for Euthanasia and Aftercare

Consent for Euthanasia and Aftercare

Please know we are here to help you through this difficult time. Should any questions arise regarding information in this form contact the hospital immediately and speak to anyone on the staff.
Date *

Month Day Year
Date
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Pet's Name *
Date of Appiontment

Month Day Year
Date
Doctor
Please list all health conditions *
Is this a new patient? *

Yes No
I certify that my pet has been vaccinated for Rabies and understand that if no proof is provided the Department of Public Health may decide my pet needs to be tested for Rabies prior to cremation and I am responsible for all costs incurred for testing. *

Yes No
If pet was vaccinated at another hospital please provide the name and phone number. If not please respond with n/a. *
Is the pet deceased on arrival to the hospital? *

Yes No
I certify that I am the owner (or legal representative of the owner) of the above named pet, and I am authorizing the humane euthanasia of this animal. I hereby release the doctor and veterinary staff of Sacajawea Veterinary Hospital from their medical responsibility for this pet.
Signature

Clear
Has this pet bitten or scratched any person or animal in the last 15 days? *

Yes No
Has this pet been bitten or scratched by another pet or wildlife in the last 15 days? *

Yes No
What are the circumstances surrounding the incident?
Has the above named pet had any exposure to wildlife (especially bats) in the last six months? *

Yes No
Has the above named pet traveled outside the Puget Sound area in the last 6 months? *

Yes No
Where did the pet travel to and how long was the pet there?
I certify that the above named pet has not bitten any person or animal during the last fifteen days, and to the best of my knowledge has not been exposed to rabies. I also certify that the answers to the above questions are true to my knowledge.
Signature

Clear
AFTERCARE OF REMAINS

I authorize the non-private cremation of my pet's remains. I understand ashes will not be returned to me. I authorize the private cremation of my pet's remains. I understand ashes will be returned to me and I am responsible for picking these up when informed of their arrival back to Sacajawea Healthcare for Pets. I choose to take my pet's remains with me to dispose of how I see fit (I understand that paw print will not be made for my pet).
Signature

Clear
Additional Options - I understand that if I do not choose an option no paw prints will be returned to me. * Paw prints are not available if you choose to take your pet's remains with you*

I would like a clay paw print I would like an ink paw print I would like both ink and clay paw prints
Should be Empty: