Euthanasia Request Form
Owner information
Today's date
*
-
Month
-
Day
Year
Date
Owner's name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Pet Information
Pet's Name
*
Pet's Species
*
Dog (canine)
Cat (feline)
Other
Pet's Birthdate (can be approximate)
*
-
Month
-
Day
Year
Date
Pet's breed
Pet's sex
*
Male (neutered)
Female (spayed)
Male (unneutered or intact)
Female (unspayed or intact)
Pet's color
Pet's weight in pounds (needs to be as accurate as possible so the proper dose of medication can be given).
*
Note: if your pet is over 40 pounds, you will need 1 additional person who can help lift and carry your pet per 25 pounds of weight over 40 pounds. E.g. if your pet weighs 90 pounds, you will need at least 2 able-bodied people to help the doctor carry the pet.
Briefly, why are you considering euthanasia for your pet?
*
Are there any distinguishing characteristics that would help me identify your pet?
Would you like me to inform another veterinarian(s) of the passing of your pet?
Yes
No
Please name the veterinarian(s) you would like us to inform.
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Final Disposition Instructions
What are your wishes for disposition for your pet?
*
Burial (owner responsibility)
Cremation (arranged and handled by Pajarito Veterinary Services and Lasting Paws)
Aquamation (water-based cremation)
Please specify other
By checking "yes" below I understand it is my responsibility to check with my Home Owner's Association and/or local government officials to determine whether or not it is legal to bury my pet in the place of my choosing. I further understand the sedatives and anesthesia used to euthanize my pet may poison other animals if ingested.
*
Yes
Would you like ashes returned to you? If you do, the cremation will be a private one and you'll get your pet's ashes and only their ashes back.
Yes
No
Would you like remains (similar to cremation ashes) returned to you? If you do, the aquamation will be a private one and you'll get your pet's remains and only theirs back.
Yes
No
Would you like a paw print?
Clay (extra $25 cost each)
Print
Digital (will be emailed to you)
None
How many footprints would you like?
What color clay would you like the print to be?
White
Pearl (off white)
Blue
Pink
Beige
Would you like a hair clipping?
Yes
No
Are there any special instructions or circumstances you would like me to be aware of?
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Legal Stuff
I hereby swear that the above mentioned pet _________________ bitten a person in the last 10 days.
*
Has
Has not
I understand if the pet has bitten someone in the last 10 days rabies testing of the pet is required by law after he/she is euthanized.
*
Yes
I, the undersigned, hereby certify that I am the legal and rightful owner of the pet mentioned above (or authorized by the legal and rightful owner). I authorize Pajarito Veterinary Services, all veterinarians, agents, staff, and representatives therein to euthanize and handle the aftercare of said animal. I release and hold harmless Pajarito Veterinary Services, all veterinarians, agents, staff, and representatives therein, from any liabilities that may arise from euthanasia, transport, and aftercare of said animal.
*
Yes
Signature
*
Your name
*
First Name
Last Name
Please verify that you are human
*
Submit
Should be Empty: