Salmon River Mobile Veterinary Clinic Euthanasia Request and Authorization

Salmon River Mobile Veterinary Clinic Euthanasia Request and Authorization

Euthanasia is the humane ending of an individual animals life due to pain and suffering caused by an injury, illness or irreversible medical condition.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Pets Name*
Species*

CatDogRabbitPocket Pet
If a pocket pet, please specify.
Breed*
Age*
Reason for euthanasia?*
Authorization

Please read, confirm, initial and date below
I certify I am 18 years old or older and the owner or authorized agent of the owner, for the above named animal.

I hearby request and fully authorize Salmon River Mobile Veterinary Clinic to perform euthanasia for the above referenced patient.

I confirm that this animal has not bitten, seriously scratched or exposed any person or animal to Rabies within the previous fifteen (15) days.

I understand that euthanasia will be performed in a humane and compassionate manner.

Fees for these services has been explained to me and will be collected at the time of service or before if I prefer to take care of finances prior to the appointment.

To the best of my knowledge, the information I have provided on this form is accurate and true.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: