Euthanasia and Disposition Consent Form

Euthanasia and Disposition Consent Form
Owner's Name*

First NameLast Name
Address*

Street Address

Apt or Unit # if needed

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*
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
Aftercare

Please choose one of the following options for the aftercare of your pet
Private Cremation

Private Cremation with Faithful Companion Pet Cremation Services $245 paid directly to FCPCS (Ashes will be returned to you)
Body Disposition Communal Cremation

I choose Communal Cremation with Faithful Companion Pet Cremation Services (Ashes will NOT be returned to you.) This includes transport to their facility ($150 paid to Forget-Me-Not)Communal cremation providing your own transport to Faithful Companion ($125 paid to FCPCS)
Body Disposition Other

Another Cremation ServiceAquamation
Body Disposition Home Burial

I choose to bury my pet at homeI would like a body bag to prevent soil and water contamination and to help protect wildlife
Home Burial Acknowledgement

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."
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
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? (not available for home burial)*

YesNo
Please indicate how many pawprints you would like. ($45 each)blanks
I am interested in a different urn or memorial product

Yes, please inform Faithful Companion
Please choose one of the following payment methods:*

Cash (exact amount needed as I do not carry cash with me)Credit Card (MC, Visa, AmEx, Discover only)Venmo
Please acknowledge the first two statements.*

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 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 regarding the Rabies law for SC.)
Signature*

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General Appearance of Pet:

Time:________Date:_____________

Drug Log:___ Card Sent:___ Email Sent:___ Mileage Log: _____ Notify Vet: _____
Should be Empty:

Euthanasia and Disposition Consent Form

Aftercare