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.
Staff
Patient ID*
Patient Name*
Species*
Breed*
Sex*

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.
To the best of your knowledge, has this pet bitten any person or animal during the last ten (10) days?*

YesNo
To the best of your knowledge. has this pet been exposed to rabies?*

YesNo
Please choose one of the following options:*

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.
Would you like to have a clay paw print made by our cremation company for $51.72 each?*

YesNo, I do not want a paw print
If the above answer is yes, how many paw prints would you like to order?
Would you like to have a hair clipping for $0?*

YesNo, I do not want a hair clipping
Signature

Clear
Should be Empty: