Euthanasia Authorization

Date

Species

Breed:

My pet is:

Pet's Age:

Color:

Client's Name:

Pet's Name:

Virginia State Law requires we ask you the following: Has your pet bitten anyone during the last 10 days?

What is your request for your loved one?

Clay paw print memorial. Please enter the number of clay paw's you would like:

Please enter your pets name as you would like it to appear on the clay paw memorial:

Phone to call when the your pet and/or clay paw memorial is ready for pick-up:

Area CodePhone Number

Disclaimer:

Clay paws and ashes that have not been picked up within 6 months of the date above may be lovingly interred in the clinic's memorial garden.

I, the owner/owner's agent hereby consent to, and request for humane reasons, euthanasia be performed on the pet described above.

Signature

Authorization to perform Euthanasia