AGF Euthanasia Consent Form

Owner's Name(s)

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
Animal's Name
Breed
Approx. Age
Weight*
Sex

MF
Spayed/Neutered?

YesNo
Reason for euthanasia
Primary veterinary hospital(s)
How did you hear about us?
Body Disposition Request

I will arrange my own aftercare service. If I choose to bury my pet at home, I understand it is my responsibility to contact my local city for regulations.Communal cremation(ashes are spread on family farm)Private cremation(return of only your pet's ashes) - Choose one:
Urn Options

Carved RosewoodPlain RosewoodWhite WashedPaw TinPhoto Urn $75Round Top w/Paw Prints $50Cylinder Urn $50
Special order urn (add'l fee)
Preferred delivery of remains

I will pick them up at the crematory (Elyria)Shipped via UPS ($30, signature required)Personally delivered ( $30, where available)
Engraved name plate- Included with WOOD urns(24 characters per line)

Yes
Line 1
Line 2
Line 3
Paw print options below are only available with cremation at crematory:
Clay Paw Print Keepsake (No charge w/private cremation $40 w/communal cremation)

Yes
Additional Clay Paw Prints ($40 Each)
Ink Prints

Ink Prints ( $15 per paw. 3 prints each)Ink Nose Print ($15. 3 each)
--I certify that I am the owner or authorized agen of the owner, for the above named animal and hereby give a A Gentle Farewell and it's Doctors full and complete authority to perform euthanasia (humanely terminate life) of my pet. Arrangements for aftercare will be based on the wishes of the owner/agent and documented above.

--To the best of my knowledge, the information I have provided on this form is true. I do also certify that this animal has not bitten any human or other animal within the last 10 days ( this is a legal point regarding Rabies).
Signature

Clear
Date

MonthDayYear
Date
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