Euthanasia Consent

Euthanasia Consent Form
Client Information
Name*

First NameLast Name
Primary Phone Number*

Area CodePhone Number
Email*
example@example.com
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address you would like the euthanasia performed (if different than permanent address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Veterinary Clinic (to inform of pet's passing)
How did you hear about Fort Wayne Mobile Vet?

Vet officeInternetFriendOther
Patient Information
Name*

First NameLast Name
Age*
Breed*
Color*
Weight (or estimated weight)*
Additional Information
If your pet is over 40 pounds, will there be someone there to help get the pet to the car in case Dr. Molly doesn't have help that day?
Additional comments (ex. any special needs, religious requests or situations in the house Dr. Molly should be aware of)
I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above; that I do hereby give the Doctor, their agents, and representatives full and complete authority to humanely euthanize the said animal.

I do hereby, and by these presents forever release the said Doctor, their agents, or representatives from any and all liability for so euthanizing the said animal.

I do also certify that the said animal has not bitten any person or animal during the last fifteen (15) days, and to the best of my knowledge has not been exposed to rabies.
Signature*

Clear
Date

MonthDayYear
Date
I further authorize the attending veterinarian to have the body cremated in accordance with hospital policy and I accept responsibility for the expense incurred.*

Individual Cremation - $550+ - Your pets' ashes are returned to you.Communal Cremation - $450 - Your pets' ashes are NOT returned to you.Other - $350 - i.e. You have a nice spot picked out to bury your pet.
Should be Empty:

Euthanasia Consent Form

Client Information

Patient Information

Additional Information