Euthanasia Authorization

Authorization to perform Euthanasia
Date *

Month Day Year
Date
Species *

Canine Feline Other
Breed: *
My pet is: *

Male Female
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? *

Yes No
What is your request for your loved one? *

Return pet to owner/owner's agent Communal cremation, ashes are not returned Private cremation, ashes are returned
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 Code Phone 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

Clear
Should be Empty:

Authorization to perform Euthanasia