Euthanasia Consent Form

Euthanasia Consent
Owner’s Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Pet’s Name*
Pet’s Age*
years
My pet is:

Neutered maleSpayed FemaleIntact MaleIntact Female
Species and breed*
ex: cat, domestic shorthair
Weight (lbs)*
Name or primary veterinarian and any additional veterinarians who care for your pet:
I request that my pet’s remains be cared for as follows:*

Private cremation with the ashes returned to me: (please see options for how you wish to receive the ashes and what type of urn you'd like below).Communal cremation (no ashes return)I will handle my pet’s remains by home burial or other arrangements
If you choose private cremation, you may select one of the following urns, which are included in the price of cremation: https://drive.google.com/file/d/1VPsA3GBSX6A-m5gVyhw5QlX1K_oFj5Jg/view?usp=sharing. Additional urns are available for purchase directly from Agape Pet Services at agapepetservices.com.

Remembrance UrnCedar Memorial UrnSerenity Photo UrnHand-carved Rosewood UrnCream colored decorative metal urnGray decorative metal urnI do not want an urn or plan to purchase a different option from Agape
If you have chosen private cremation, you may enter up to 3 lines of text to be engraved, (30 characters per line) on a plaque (wooden urns) or 2 lines of text (25 characters per line) directly onto the urn (metal urns). If nothing is entered, the urn will be engraved with "In Loving Memory of (pet's name)"
For private cremation, we have several options for returning your beloved pet’s cremains to you afterwards. Unless previously arranged with Agape, the cremains usually take 1-2 weeks to be returned. Please choose an option that works best for your family below:

Returned to my primary veterinarian (you must provide a name for the hospital above) at no additional cost. We will notify you when they urn and cremains have been delivered.Hand delivered to my home (additional $15-125 depending on location, similar to the travel fee quoted). We can’t hand deliver urns to families who live more than 40 miles from Maymont/Byrd Park areaShipped to my home via UPS for an additional $35I will pick my pet’s remains up directly from Agape Pet Services at 1001 Techpark Place, Sandston, VA 23150 at no additional cost.
Would you like us to provide a memorial item to leave with you after your pet passes? (a fur clipping and the one paw pals impression print are included with our service, and additional paw/nose prints are $10 for ink and $20 for paw pals impression).*

Paw pals impression print (https://www.pawpalorders.com/Public/PhotoGallery.aspx)--complimentary if you would like oneInk paw printInk nose printFur clipping-complimentary/includedNo thank you, I do not want fur clippings or any paw prints.Other
I am the owner (or authorized agent of the owner) of the animal described above. I hereby order and give Lovingkindness Veterinary Care and its personnel complete authority to euthanize my pet in whatever humane manner they deem appropriate, and to care for their body afterwards as specified above and in accordance with their policy. I hereby forever release Lovingkindness Veterinary Care and its personnel from any liability that may arise from euthanizing or handling of my pet.

To the best of my knowledge my pet has not bitten any person or animal during the past ten (10) days, nor has my pet ever been exposed to rabies.
Signature

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Name

First NameLast Name
Date

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