Euthanasia and Disposition Consent Form

Owner's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Mobile Phone Number*

Please enter a valid phone number.

Second Contact Number

Please enter a valid phone number.

Email*

example@example.com

Animal's Name*

Breed*

Approximate Age*

Weight*

Sex*

MaleFemale

Spayed/Neutered?*

YesNo

Up to Date on Rabies Vaccination*

YesNo

Reason for Euthanasia*

Primary Vet Hospital*

Would you like your regular veterinarian to be notified of your pet's passing?*

YesNo

Body Disposition - Please select only those that apply*

Private Cremation with Faithful Companion Pet Cremation Services $245 paid directly to FCPCS (Ashes will be returned to you - please see https://faithfulcompanion.com/locations/columbia/ for more information.)I choose Communal Cremation with Faithful Companion Pet Cremation Services (Ashes will NOT be returned to you, but will be interred at a pet cemetery.) $100 if require FCPCS to provide transport.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. South Carolina law states "when buried, an animal shall be put not less than three feet under the ground. Cases of suspected wildlife death from animal remains containing pentobarbital are investigated by the regional US Fish and Wildlife Service law enforcement office. Animal remains containing pentobarbital are potentially poisonous for scavenging wildlife, including birds of prey, carnivorous mammals, and domestic dogs and cats. Federal laws protecting many of these species apply to secondary poisoning from animal remains that contain pentobarbital and may carry civil and criminal penalties, with fines up to $500,000 and incarceration for up to 2 years.I would like a body bag for my use during home burial (included in euthanasia cost). The bag is purposely designed not to put wildlife and pets at riskCremation or Aquamation service with another provider

Private cremation includes a wooden urn provided by Faithful Companions Pet Cremation. The urn can have up to 2 lines of engraving.
Please enter what you would like on Line 1: blanks
Line 2: blank

If you choose communal cremation, will you need our assistance to transport your pet to Faithful Companion Pet Cremation Services? ($100 fee)*

YesNoNot applicable (Home burial or Private Cremation selected)

Would you like a clipping of fur as a keepsake (included upon request for communal and private cremation, not for home burial)?*

YesNo

Please indicate how many clipping containers you would like (no additional charge): blanks

Pawprints are provided by Faithful Companion for $45 each for both communal and private cremations. Would you like a pawprint to be made?*

YesNo

Please indicate how many pawprints you would like. ($45 each)blanks

Please choose one of the following payment methods:*

Cash (exact amount needed as I do not carry cash with me)Credit CardVenmo

--I certify that I am the owner or authorized agent of the owner and that I am at least 18 years of age, for the above-named animal and hereby give a Forget-Me-Not Veterinary and its Doctors 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 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.)

Signature*

General Appearance of Pet:

TA:_________ Torb:________X:________Euth:________

Time:________Date:_____________

Total$______

Cash ____Check#______ Credit Card ____ Venmo _____ Paypal _____

Drug Log:___ Card Sent:___ Email Sent:___ Mileage Log: _____ Notify Vet: _____