Coastal Animal Medical Center Euthanasia Authorization

Coastal Animal Medical Center Euthanasia Authorization
Client ID*
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Staff
Patient ID*
Patient Name*
Species*
Breed*
MaleFemale
Color*
Date of birth*
I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give the doctors of Coastal Animal Medical Center, LLC permission to euthanize and dispose of said animal in the manner selected below. I also release the doctors, Coastal Animal Medical Center, LLC , their agents, servants and representatives for any and all liability for so euthanizing and disposing of said animal.
YesNo
YesNo
I choose to take my pet's remains home with me today.I choose to have my pet's remains cremated. I understand it is not a private cremation, and the ashes will not be returned to me.I choose to have my pet's remains privately cremated and the ashes returned to me.
YesNo, I do not want a paw print
If the above answer is yes, how many paw prints would you like to order?
YesNo, I do not want a hair clipping
Signature

Clear
Should be Empty: