Euthanasia and Disposition Consent Form

Euthanasia and Disposition Consent Form
Owner's Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Animal's Name *
Breed *
Approximate Age *
Weight *
Sex *

Male Female
Spayed/Neutered? *

Yes No
Up to Date on Rabies Vaccination *

Yes No
Reason for Euthanasia *
Primary Vet Hospital *
Would you like your regular veterinarian to be notified of your pet's passing? *

Yes No
How Did You Hear About Us?
Body Disposition *

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/county for regulations. Burying a euthanized pet can put other pets and wildlife at risk for death if not done properly. Communal Cremation with Columbia Pet Cremation (Ashes will NOT be returned to you, but will be scattered in a dignified manner. Individual or Private Cremation with Columbia Pet Cremation (Ashes will be returned to you - please see www.colapetcremation.com for more information.) Cremation service with another provider
Will you need our assistance to transport your pet to Columbia Pet Cremation Center? *

Yes No
A Pawpals impression print of your pet's paw and/or a glass vial for fur clipping can be provided to those choosing to bury their pet at their home. Please select if you would like either of these options. *

Pawprint for $30 Glass Vial and Fur Clipping $15 Do Not Need or Crematory is Providing
Please choose one of the following payment methods: *

Cash (exact amount needed as I do not carry cash on me) Check Credit Card (Square) Venmo
--I certify that I am the owner or authorized agent of the owner, for the above named animal and hereby give a Forget-Me-Not Veterinary 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 question is in regards to Rabies law for SC.)
By typing your name on this document, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. You also confirm that you are the individual named in this electronic signature, and that you are authorized to sign this document. *

I agree
Owner/Agent Signature (By typing name, *
Date *

Month Day Year
Date
TA:_________Bot:________

Torb:________Bot:________

X:________

Euth:________Bot:________

Time:________Date:_____________

Clinician Signature:_____________________________

Euth$______ After$______Misc$______ Total$______

Cash ____Check#______ Credit Card Last 4: ______________

Drug Log:________ Card Sent:_______ Email Sent:_______
Should be Empty:

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