Euthanasia Authorization

Date*

Date

Species*

CanineFelineOther

Breed:*

My pet is:*

MaleFemale

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?*

YesNo

What is your request for your loved one?*

Private cremation, ashes are returned.Communal cremation, ashes are not returned.Return pet to owner/owner's agent for burial.

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